Provider Demographics
NPI:1679869473
Name:KOMORI, ALLYSON J (DO)
Entity type:Individual
Prefix:
First Name:ALLYSON
Middle Name:J
Last Name:KOMORI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ALLYSON
Other - Middle Name:J
Other - Last Name:COONTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 W FORT ST. #111
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 W FORT ST # 111
Practice Address - Street 2:SUITE 202
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-695-3774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMRO1313207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine