Provider Demographics
NPI:1083774368
Name:KOMM, GREGORY THEODORE (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:THEODORE
Last Name:KOMM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N BROOK LN
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-2610
Mailing Address - Country:US
Mailing Address - Phone:301-654-7180
Mailing Address - Fax:301-664-9691
Practice Address - Street 1:111 N BROOK LN
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-2610
Practice Address - Country:US
Practice Address - Phone:301-654-7180
Practice Address - Fax:301-664-9691
Is Sole Proprietor?:No
Enumeration Date:2006-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1193174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD00A921K38Medicare ID - Type Unspecified
MDU44515Medicare UPIN