Provider Demographics
NPI:1811526494
Name:MANDSAGER KOMATSU, JULIA ANNE
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:ANNE
Last Name:MANDSAGER KOMATSU
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 1:2207 BOSTON ROAD
Mailing Address - Street 2:
Mailing Address - City:WILBRAHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01095
Mailing Address - Country:US
Mailing Address - Phone:413-599-1201
Mailing Address - Fax:413-596-2940
Practice Address - Street 1:2207 BOSTON ROAD
Practice Address - Street 2:
Practice Address - City:WILBRAHAM
Practice Address - State:MA
Practice Address - Zip Code:01095
Practice Address - Country:US
Practice Address - Phone:413-599-1201
Practice Address - Fax:413-596-2940
Is Sole Proprietor?:No
Enumeration Date:2020-04-05
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10158652080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110201385AMedicaid