Healthcare Provider Details

I. General information

NPI: 1295373744
Provider Name (Legal Business Name): KOMAL PATEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 LLEWELLYN AVE
FORT MEADE MD
20755-7081
US

IV. Provider business mailing address

2480 LLEWELLYN AVE
FORT MEADE MD
20755-7081
US

V. Phone/Fax

Practice location:
  • Phone: 301-677-8800
  • Fax: 301-677-8013
Mailing address:
  • Phone: 301-677-8800
  • Fax: 301-677-8013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR219909
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR219909
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: