Provider Demographics
NPI:1033212279
Name:KNOWLES, BRIAN KEVIN (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEVIN
Last Name:KNOWLES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 W. LOCKLING ST
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:64628-2336
Mailing Address - Country:US
Mailing Address - Phone:660-258-3363
Mailing Address - Fax:660-258-5409
Practice Address - Street 1:624 W. LOCKLING ST
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:MO
Practice Address - Zip Code:64628-2336
Practice Address - Country:US
Practice Address - Phone:660-258-3363
Practice Address - Fax:660-258-5409
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9F17207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242289007Medicaid
MO242289007Medicaid
MO900315465Medicare PIN