Provider Demographics
NPI:1992094734
Name:KOMATSUBARA, KIMBERLY MAYUMI (MD)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:MAYUMI
Last Name:KOMATSUBARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:177 FORT WASHINGTON AVE
Mailing Address - Street 2:MHB 6GN435
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3733
Mailing Address - Country:US
Mailing Address - Phone:646-317-6041
Mailing Address - Fax:
Practice Address - Street 1:161 FORT WASHINGTON AVE FL 9
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3729
Practice Address - Country:US
Practice Address - Phone:646-317-6041
Practice Address - Fax:212-305-6891
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2018-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA122622207R00000X
NY274649207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program