Provider Demographics
NPI:1861433302
Name:KOMASARA, DAVID (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:KOMASARA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28868 SALEM RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011074207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114287137Medicaid
MIDK011074OtherBC/BS OF MICHIGAN
MI114713696Medicaid
MI113377937Medicaid
MI114274961Medicaid
MIF72589Medicare UPIN
MI114713696Medicaid