Provider Demographics
NPI:1003109745
Name:KNUTSON, THOMAS JOHN (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:KNUTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7500 N DREAMY DRAW DR STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4668
Mailing Address - Country:US
Mailing Address - Phone:480-882-4545
Mailing Address - Fax:480-882-5814
Practice Address - Street 1:11851 N 51ST AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-2809
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:480-882-5814
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-26
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS252552084P0800X
MO20220257382084P0800X
AZ536862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ151850Medicaid