Healthcare Provider Details

I. General information

NPI: 1407799497
Provider Name (Legal Business Name): KOMLAN JOSE AFEZUKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BAUGHMANS LN
FREDERICK MD
21702-4059
US

IV. Provider business mailing address

30 N GOULD ST # 37530
SHERIDAN WY
82801-6317
US

V. Phone/Fax

Practice location:
  • Phone: 443-410-4644
  • Fax:
Mailing address:
  • Phone: 443-410-4644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: