Provider Demographics
NPI:1134700719
Name:KOMRO, JACK (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:KOMRO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3531 GREENWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-2216
Mailing Address - Country:US
Mailing Address - Phone:715-495-5640
Mailing Address - Fax:
Practice Address - Street 1:30117 SCHOENHERR RD STE 400
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-6854
Practice Address - Country:US
Practice Address - Phone:586-738-9470
Practice Address - Fax:586-738-9469
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program