Provider Demographics
NPI:1124720693
Name:KOMETAS, MARISA LEIGH (MD)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:LEIGH
Last Name:KOMETAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4232 S PENINSULA DR
Mailing Address - Street 2:
Mailing Address - City:WILBUR BY THE SEA
Mailing Address - State:FL
Mailing Address - Zip Code:32127-6618
Mailing Address - Country:US
Mailing Address - Phone:386-341-9694
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7201
Practice Address - Country:US
Practice Address - Phone:385-341-9694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program