Provider Demographics
NPI:1013914894
Name:KOMM, KEVIN DOUGLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DOUGLAS
Last Name:KOMM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 SUNDOWN TRL
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2202
Mailing Address - Country:US
Mailing Address - Phone:716-689-9534
Mailing Address - Fax:716-689-9534
Practice Address - Street 1:900 CENTER ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1737
Practice Address - Country:US
Practice Address - Phone:716-754-2555
Practice Address - Fax:716-754-8650
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT004540152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY003900255OtherCOMMUNITY BLUE
NY7209530OtherINDEPENTENT HEALTH
NYNY4540OtherEYEMED
NY32212OtherCOLE MANAGED CARE
NY000102319-01OtherUNIVERA
NY003900255OtherCOMMUNITY BLUE