Provider Demographics
NPI:1750373585
Name:KOMRO, NICHOLAS JOEL (OD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JOEL
Last Name:KOMRO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-2516
Mailing Address - Country:US
Mailing Address - Phone:715-235-2855
Mailing Address - Fax:715-235-9436
Practice Address - Street 1:520 WILSON AVE
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2516
Practice Address - Country:US
Practice Address - Phone:715-235-2855
Practice Address - Fax:715-235-9436
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2903-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38719700Medicaid
U92225Medicare UPIN
WIP00090116Medicare PIN