Provider Demographics
NPI:1003800434
Name:JEFFREY C. KOMENDA, M.D., P.A.
Entity Type:Organization
Organization Name:JEFFREY C. KOMENDA, M.D., P.A.
Other - Org Name:FAMILY MEDICINE AT WILLOW BEND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:KOMENDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-608-1868
Mailing Address - Street 1:5944 W PARKER RD
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-6422
Mailing Address - Country:US
Mailing Address - Phone:972-608-1868
Mailing Address - Fax:972-943-8644
Practice Address - Street 1:5944 W PARKER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-6421
Practice Address - Country:US
Practice Address - Phone:972-608-1868
Practice Address - Fax:972-943-8644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6350261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124934405Medicaid
TX165802302Medicaid
TX10018514OtherAMERIGROUP
TX165802301Medicaid
TX00964WMedicare PIN
TX165802302Medicaid