Basic Information
| Provider Information | |||||||||
| NPI: | 1558335786 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOMRY | ||||||||
| FirstName: | VICTOR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28 CHEROKEE RD | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020211235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815620404 | ||||||||
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| Practice Location | |||||||||
| Address1: | 70 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TAUNTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027802736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088217777 | ||||||||
| FaxNumber: | 5088222601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 56500 | MA | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 56500 | MA | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 3091309 | 05 | MA | MEDICAID |