Provider Demographics
NPI:1033284286
Name:KNUDSON, GREGORY S (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:KNUDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7527
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-0727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:551 W CENTRAL AVE STE 102
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-1498
Practice Address - Country:US
Practice Address - Phone:740-368-5550
Practice Address - Fax:740-368-5591
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.063160208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000014762OtherANTHEM BCBS
1900506OtherUNITED HEALTHCARE-S
1900116OtherUNITED HEALTHCARE-M&D
340006194OtherRR MEDICARE
OH0004221655OtherAETNA
OH0871187Medicaid
OHKN0712055Medicare PIN
OH0004221655OtherAETNA
OH0871187Medicaid