MEDICARE: DR. JASON JON KOMITAU M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	35084871	OH

General Provider Information

NPI Number	:	1356340152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON JON KOMITAU M.D.

Provider Business Mailing Address
First Line	:	30033 CLEMENS RD
Second Line	:
City	:	WESTLAKE
State	:	OH
Zip	:	44145-1021
Country	:	US
Telephone Number	:	440-899-5555
Fax Number	:	440-808-2995

Provider Business Practice Location Address
First Line	:	30033 CLEMENS RD
Second Line	:
City	:	WESTLAKE
State	:	OH
Zip	:	44145-1021
Country	:	US
Telephone Number	:	440-899-5555
Fax Number	:	440-808-2995

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	02/14/2008

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