Basic Information
| Provider Information | |||||||||
| NPI: | 1669443602 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANG | ||||||||
| FirstName: | KOMAL | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11202 OLD CARRIAGE RD | ||||||||
| Address2: | |||||||||
| City: | GLEN ARM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210579415 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3455 WILKENS AVE | ||||||||
| Address2: | L 10 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212295213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106460555 | ||||||||
| FaxNumber: | 4106444484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2006 | ||||||||
| LastUpdateDate: | 06/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | D18362 | MD | N | Other Service Providers | Specialist | 261QP2300X | D0018362 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 257951100 | 05 | MD | MEDICAID |