Basic Information
| Provider Information | |||||||||
| NPI: | 1053790816 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOMOLAFE | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | IYABO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 WEST ST | ||||||||
| Address2: | |||||||||
| City: | CARTHAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136199703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008939698 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL PARK | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042433000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2015 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 28344 | WV | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 21826 | NH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 302898 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.