Provider Demographics
NPI:1972678753
Name:KOMOTO, TIMOTHY S (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:S
Last Name:KOMOTO
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 1:200 BUNKER HILL DR
Mailing Address - Street 2:
Mailing Address - City:AITKIN
Mailing Address - State:MN
Mailing Address - Zip Code:56431-1865
Mailing Address - Country:US
Mailing Address - Phone:218-927-2157
Mailing Address - Fax:218-927-4130
Practice Address - Street 1:200 BUNKER HILL DR
Practice Address - Street 2:
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431-1865
Practice Address - Country:US
Practice Address - Phone:218-927-2157
Practice Address - Fax:218-927-4130
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN411008100Medicaid
MN080015564OtherMEDICARE WPS - HOSPITAL
MN080015565OtherMEDICARE WPS - AITKIN CLI
MN080015846OtherMEDICARE WPS - GARRISON C
MN080015566OtherMEDICARE WPS - MCGREGOR C
MN080015566OtherMEDICARE WPS - MCGREGOR C