Provider Demographics
NPI:1760453518
Name:KOMMOR, MICHAEL DEVON (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEVON
Last Name:KOMMOR
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2700 STANLEY GAULT PKWY
Mailing Address - Street 2:STE 129
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4917
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:4003 KRESGE WAY
Practice Address - Street 2:SUITE 500
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-897-1166
Practice Address - Fax:502-897-1461
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2020-12-07
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Provider Licenses
StateLicense IDTaxonomies
KY27861207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000652535OtherANTHEM
KY64278617Medicaid
KY3770421000OtherPASSPORT ADVANTAGE
KY50027652OtherPASSPORT
KY000000652535OtherANTHEM
E56415Medicare UPIN