Provider Demographics
NPI:1003800012
Name:KNUTSON, JONATHAN GLYNDON (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:GLYNDON
Last Name:KNUTSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5630 S 84TH ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-4427
Mailing Address - Country:US
Mailing Address - Phone:402-488-2211
Mailing Address - Fax:
Practice Address - Street 1:5630 S 84TH ST
Practice Address - Street 2:SUITE 120
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-4427
Practice Address - Country:US
Practice Address - Phone:402-488-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1147152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE36755OtherBCBS
NE275868Medicare ID - Type Unspecified
NE275761Medicare ID - Type Unspecified
U76085Medicare UPIN