1396934865 NPI number — DR. JEFFREY CRAIG KOMENDA M.D.

Table of content: DR. JEFFREY CRAIG KOMENDA M.D. (NPI 1396934865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396934865 NPI number — DR. JEFFREY CRAIG KOMENDA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOMENDA
Provider First Name:
JEFFREY
Provider Middle Name:
CRAIG
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KOMENDA
Provider Other First Name:
JEFF
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1396934865
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5944 W PARKER RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75093-6422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-608-1868
Provider Business Mailing Address Fax Number:
972-943-8644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5944 W PARKER RD
Provider Second Line Business Practice Location Address:
100
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75093-6421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-608-1868
Provider Business Practice Location Address Fax Number:
972-943-8644
Provider Enumeration Date:
10/19/2007

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: 207Q00000X , with the licence number:  H6350 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10018514 . This is a "AMERIGROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 165802301 . This is a "MEDICAID GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 165802302 . This is a "MEDICAID TEXAS HEALTH STE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 124934405 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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