Provider Demographics
NPI:1437104858
Name:KOMIN, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:KOMIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 E LERDO HWY
Mailing Address - Street 2:# C
Mailing Address - City:SHAFTER
Mailing Address - State:CA
Mailing Address - Zip Code:93263-9417
Mailing Address - Country:US
Mailing Address - Phone:661-630-5890
Mailing Address - Fax:
Practice Address - Street 1:1150 E LERDO HWY
Practice Address - Street 2:#C
Practice Address - City:SHAFTER
Practice Address - State:CA
Practice Address - Zip Code:93263-9417
Practice Address - Country:US
Practice Address - Phone:661-630-5890
Practice Address - Fax:661-630-5896
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76214207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH93939Medicare UPIN
CAZZZ01838ZMedicare ID - Type Unspecified