1972788628 NPI number — JEFFREY C. KOMENDA, M.D., P.A.

Table of content: (NPI 1972788628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972788628 NPI number — JEFFREY C. KOMENDA, M.D., P.A.

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1972788628
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2008
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:
1305 S SH 121
Provider Second Line Business Practice Location Address:
STE C-108
Provider Business Practice Location Address City Name:
LEWISVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75067-5915
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:
12/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KOMENDA
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
TICKLE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
972-608-1868

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , 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: 165802301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 165802302 . This is a "MEDICAID HEALTH STEPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 10018514 . This is a "AMERIGROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8AJ618 . This is a "BC/BS INDIVIDUAL" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0007QN . This is a "BC/BS GROUP NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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