Basic Information
| Provider Information | |||||||||
| NPI: | 1972678753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOMOTO | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 BUNKER HILL DR | ||||||||
| Address2: | |||||||||
| City: | AITKIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564311865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2189272157 | ||||||||
| FaxNumber: | 2189274130 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 BUNKER HILL DR | ||||||||
| Address2: | |||||||||
| City: | AITKIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564311865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2189272157 | ||||||||
| FaxNumber: | 2189274130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 26655 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 411008100 | 05 | MN | MEDICAID | 080015564 | 01 | MN | MEDICARE WPS - HOSPITAL | OTHER | 080015565 | 01 | MN | MEDICARE WPS - AITKIN CLI | OTHER | 080015846 | 01 | MN | MEDICARE WPS - GARRISON C | OTHER | 080015566 | 01 | MN | MEDICARE WPS - MCGREGOR C | OTHER |