Healthcare Provider Details

I. General information

NPI: 1790882439
Provider Name (Legal Business Name): ASHOK K KOMARLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 E 139TH AVE
TAMPA FL
33613-3420
US

IV. Provider business mailing address

12512 BRUCE B DOWNS BLVD
TAMPA FL
33612-9209
US

V. Phone/Fax

Practice location:
  • Phone: 813-972-2705
  • Fax: 813-632-0933
Mailing address:
  • Phone: 813-977-8700
  • Fax: 813-971-2029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME54582
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberME54582
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME54582
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: