Provider Demographics
NPI:1124297213
Name:KOMARIDIS, GEORGE V (PHD LP)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:V
Last Name:KOMARIDIS
Suffix:
Gender:M
Credentials:PHD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11 CIVIC CENTER PLZ STE 205
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-7718
Mailing Address - Country:US
Mailing Address - Phone:507-345-4679
Mailing Address - Fax:507-345-8685
Practice Address - Street 1:11 CIVIC CENTER PLZ STE 2090
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-7710
Practice Address - Country:US
Practice Address - Phone:507-345-4679
Practice Address - Fax:507-345-8685
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-22
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1673103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN264547500Medicaid