1164442836 NPI number — MR. PETER KOMATZ ARNP

Table of content: MR. PETER KOMATZ ARNP (NPI 1164442836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164442836 NPI number — MR. PETER KOMATZ ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOMATZ
Provider First Name:
PETER
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164442836
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2650 N TENAYA WAY
Provider Second Line Business Mailing Address:
STE 301
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89128-1112
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-216-3346
Provider Business Mailing Address Fax Number:
702-671-6883

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1235 SAN MARCO BLVD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32207-8554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-493-5100
Provider Business Practice Location Address Fax Number:
904-493-5130
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  ARNP 2914192 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 813635 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: ARNP2914192 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 370760 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: Y03Q8 . This is a "BCBS-FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1127401 . This is a "CAREPLUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 9352274 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P302336 . This is a "OPTIMUM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P0022953 . This is a "FLORIDA HEALTHCARE PLUS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P01593271 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 3088511-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 788049 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P306625 . This is a "FREEDOM HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1193321 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 12444 . This is a "UNIVERSAL HEALTHCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P00808198 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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