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General NPI Number Information
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NPI Number | 1639395270
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Entity Type | Organization
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Legal Business Name | MICHAEL L. KOMASINSKI
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Dates
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Enumeration Date | 04/18/2007
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Last Update Date | 11/09/2012
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Provider Practice Location Address
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Address Line | 106 LEGACY PLZ W
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City | LA PORTE
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State | IN
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Zip | 46350-5298
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Country | US
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Telephone | 219-362-2685
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Fax | 219-362-5587
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Provider Business Mailing Address
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Address Line | 106 LEGACY PLZ W
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City | LA PORTE
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State | IN
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Zip | 46350-5298
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Country | US
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Telephone | 219-362-2685
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Fax | 219-362-5587
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. MICHAEL L KOMASINSKI
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Credential | O.D.
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Telephone | 219-362-2685
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 18002319
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License Number State | IN
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