Healthcare Provider Details

I. General information

NPI: 1265478697
Provider Name (Legal Business Name): ANDREW LEWIS KOMINSKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 N SCHREIBER WAY UNIT 101
COEUR D ALENE ID
83815-8434
US

IV. Provider business mailing address

3815 N SCHREIBER WAY UNIT 101
COEUR D ALENE ID
83815-8434
US

V. Phone/Fax

Practice location:
  • Phone: 208-755-2804
  • Fax: 208-765-0277
Mailing address:
  • Phone: 208-755-2804
  • Fax: 208-765-0277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number2061972
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberMD00046940
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMD00046940
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number2061972
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: