Provider Demographics
NPI:1639395270
Name:MICHAEL L. KOMASINSKI
Entity Type:Organization
Organization Name:MICHAEL L. KOMASINSKI
Other - Org Name:EYE ASSOCIATES OF LAPORTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:KOMASINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:219-362-2685
Mailing Address - Street 1:106 LEGACY PLZ W
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-5298
Mailing Address - Country:US
Mailing Address - Phone:219-362-2685
Mailing Address - Fax:219-362-5587
Practice Address - Street 1:106 LEGACY PLZ W
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-5298
Practice Address - Country:US
Practice Address - Phone:219-362-2685
Practice Address - Fax:219-362-5587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002319152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200445030AMedicaid
IN0525800001Medicare NSC
IN489780Medicare PIN