Provider Demographics
NPI:1548874605
Name:KHATTAK, KOMAL GULAB
Entity type:Individual
Prefix:
First Name:KOMAL
Middle Name:GULAB
Last Name:KHATTAK
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 1:10 FEATHERBED LN
Mailing Address - Street 2:
Mailing Address - City:AUDUBON
Mailing Address - State:PA
Mailing Address - Zip Code:19403-2055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3B, 186 PRINCETON HIGHTSTOWN RD
Practice Address - Street 2:#104
Practice Address - City:WEST WINDSOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08550
Practice Address - Country:US
Practice Address - Phone:609-799-8444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00772700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty