Provider Demographics
NPI:1457303588
Name:KOMATZ, KELLY C (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:C
Last Name:KOMATZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 SUMMER AVE
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33469-3119
Mailing Address - Country:US
Mailing Address - Phone:904-428-9197
Mailing Address - Fax:
Practice Address - Street 1:1519 SUMMER AVE
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33469-3119
Practice Address - Country:US
Practice Address - Phone:904-428-9197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61036208000000X, 2080H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257235401Medicaid
FLF24877Medicare UPIN
FL15856VMedicare PIN
FL14856WMedicare ID - Type Unspecified