Basic Information
| Provider Information | |||||||||
| NPI: | 1841253101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNUTSON | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 183103 | ||||||||
| Address2: | 660 ACKERMAN 3RD FLOOR | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432183108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142932150 | ||||||||
| FaxNumber: | 6142936479 | ||||||||
| Practice Location | |||||||||
| Address1: | 2231 NORTH HIGH STREET | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142932700 | ||||||||
| FaxNumber: | 6142932720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2006 | ||||||||
| 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 | 207Q00000X | 35057368 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2024562 | 05 | OH | MEDICAID |