Basic Information
| Provider Information | |||||||||
| NPI: | 1003800012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNUTSON | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | GLYNDON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5630 S 84TH ST | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685164427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024882211 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5630 S 84TH ST | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685164427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024882211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 07/20/2007 | ||||||||
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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 | 152W00000X | 1147 | NE | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 36755 | 01 | NE | BCBS | OTHER |