Provider Demographics
NPI:1760902464
Name:IMTIAZ, KOMAL
Entity type:Individual
Prefix:DR
First Name:KOMAL
Middle Name:
Last Name:IMTIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 STANTONSBURG RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-2818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 DOCTORS DR STE B
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-1584
Practice Address - Country:US
Practice Address - Phone:252-559-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2024-03166207RC0000X
MI5315086346207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease