Provider Demographics
NPI:1730143835
Name:KOMOROWSKI, SUSAN M (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:KOMOROWSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3533 SOUTHERN BLVD
Mailing Address - Street 2:STE 4600
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1273
Mailing Address - Country:US
Mailing Address - Phone:937-296-0167
Mailing Address - Fax:937-297-2330
Practice Address - Street 1:3533 SOUTHERN BLVD
Practice Address - Street 2:STE 4600
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1273
Practice Address - Country:US
Practice Address - Phone:937-296-0167
Practice Address - Fax:937-297-2330
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH056772207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000009385OtherANTHEM
OH0723417Medicaid
BK2279190OtherDEA
BK2279190OtherDEA
K00679553Medicare ID - Type Unspecified