Provider Demographics
NPI:1568446508
Name:KOMORN, HARVEY J (MD)
Entity type:Individual
Prefix:DR
First Name:HARVEY
Middle Name:J
Last Name:KOMORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3535 W 13 MILE RD
Mailing Address - Street 2:SUITE 247
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6710
Mailing Address - Country:US
Mailing Address - Phone:248-551-6520
Mailing Address - Fax:248-551-6020
Practice Address - Street 1:3535 W 13 MILE RD
Practice Address - Street 2:SUITE 247
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6710
Practice Address - Country:US
Practice Address - Phone:248-551-6520
Practice Address - Fax:248-551-6020
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301024827208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1016480Medicaid
0634726021Medicare ID - Type Unspecified
A77322Medicare UPIN