Healthcare Provider Details

I. General information

NPI: 1134700719
Provider Name (Legal Business Name): JACK KOMRO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1087 W MASON ST
GREEN BAY WI
54303-1859
US

IV. Provider business mailing address

1087 W MASON ST
GREEN BAY WI
54303-1859
US

V. Phone/Fax

Practice location:
  • Phone: 920-499-3102
  • Fax:
Mailing address:
  • Phone: 920-499-3102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberV6616
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number82077-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: