Healthcare Provider Details

I. General information

NPI: 1164840906
Provider Name (Legal Business Name): RAHUL KOMATI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2014
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE # MC2114
CHICAGO IL
60637
US

IV. Provider business mailing address

1100 JOHNSON FERRY RD STE 593
ATLANTA GA
30342-1733
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1864
  • Fax:
Mailing address:
  • Phone: 404-255-9096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301105302
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number84855
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number036.146605
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: