Provider Demographics
NPI:1376930099
Name:KOMAR, JOANNA (OD)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:KOMAR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11718 ROCKAWAY BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-2018
Mailing Address - Country:US
Mailing Address - Phone:718-634-5808
Mailing Address - Fax:
Practice Address - Street 1:11718 ROCKAWAY BEACH BLVD
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-2018
Practice Address - Country:US
Practice Address - Phone:718-634-5808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008333152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program