Provider Demographics
NPI:1063645877
Name:KNUDSON, DALE ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:ALLEN
Last Name:KNUDSON
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 1:385 W CORAL DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-7529
Mailing Address - Country:US
Mailing Address - Phone:503-330-6942
Mailing Address - Fax:
Practice Address - Street 1:900 INDIANA AVE
Practice Address - Street 2:SUITE # D
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3766
Practice Address - Country:US
Practice Address - Phone:719-561-2812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2743152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist