Basic Information
| Provider Information | |||||||||
| NPI: | 1760443949 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | KOMJATHY | ||||||||
| FirstName: | GABRIEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43 | ||||||||
| Address2: | MR 10809 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554400043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122624813 | ||||||||
| FaxNumber: | 6122624194 | ||||||||
| Practice Location | |||||||||
| Address1: | 3960 COON RAPIDS BLVD NW | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6125767600 | ||||||||
| FaxNumber: | 6125767610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 35430 | MN | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.