MEDICARE: DR. KEVIN DOUGLAS KOMM O.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	152W00000X	Optometrist	VUT004540	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	003900255	OTHER	NY	COMMUNITY BLUE
2	7209530	OTHER	NY	INDEPENTENT HEALTH
3	NY4540	OTHER	NY	EYEMED
4	32212	OTHER	NY	COLE MANAGED CARE
5	000102319-01	OTHER	NY	UNIVERA

General Provider Information

NPI Number	:	1013914894
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN DOUGLAS KOMM O.D.

Provider Business Mailing Address
First Line	:	222 SUNDOWN TRL
Second Line	:
City	:	WILLIAMSVILLE
State	:	NY
Zip	:	14221-2202
Country	:	US
Telephone Number	:	716-689-9534
Fax Number	:	716-689-9534

Provider Business Practice Location Address
First Line	:	900 CENTER ST
Second Line	:
City	:	LEWISTON
State	:	NY
Zip	:	14092-1737
Country	:	US
Telephone Number	:	716-754-2555
Fax Number	:	716-754-8650

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	02/28/2012

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Directions to “ DR. KEVIN DOUGLAS KOMM O.D.” Practice Location

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