MEDICARE: DR. SHYAM KOMANDUR MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	96-00975	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184616583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHYAM KOMANDUR MD

Provider Business Mailing Address
First Line	:	PO BOX 41209
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28309-1209
Country	:	US
Telephone Number	:	910-609-6448
Fax Number	:	910-609-7040

Provider Business Practice Location Address
First Line	:	101 ROBESON ST
Second Line	:	SUITE 300
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28301-5552
Country	:	US
Telephone Number	:	910-609-1616
Fax Number	:	910-609-1619

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	07/09/2007

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