Provider Demographics
NPI:1962287532
Name:GUMMADIVALLY, KOMAL
Entity type:Individual
Prefix:
First Name:KOMAL
Middle Name:
Last Name:GUMMADIVALLY
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 1:179 7TH ST
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-5429
Mailing Address - Country:US
Mailing Address - Phone:316-300-6972
Mailing Address - Fax:
Practice Address - Street 1:820 HEMSTEAD TURNPIKE
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:11010
Practice Address - Country:US
Practice Address - Phone:516-440-2277
Practice Address - Fax:516-358-8960
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050651225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist