Healthcare Provider Details

I. General information

NPI: 1306417308
Provider Name (Legal Business Name): KOMAL PATEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 03/21/2026
Certification Date: 03/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 E ROOSEVELT ST
PHOENIX AZ
85008-4973
US

IV. Provider business mailing address

2601 E ROOSEVELT ST
PHOENIX AZ
85008-4973
US

V. Phone/Fax

Practice location:
  • Phone: 602-344-5011
  • Fax:
Mailing address:
  • Phone: 602-344-5011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-002925
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3146
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: