Provider Demographics
NPI:1174620272
Name:KOMAROMY, MIRIAM SUZANNE (MD)
Entity type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:SUZANNE
Last Name:KOMAROMY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MIRIAM
Other - Middle Name:SUZANNE
Other - Last Name:HUACO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:720 HARRISON AVE DOB 503
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CTR PL
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2908
Practice Address - Country:US
Practice Address - Phone:617-414-4580
Practice Address - Fax:617-414-4572
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA281405207R00000X, 207RA0401X, 2083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM25231871Medicaid
NM25231871Medicaid