Provider Demographics
NPI:1093750291
Name:KNUTH, KEITH R (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:R
Last Name:KNUTH
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 1:901 E 86TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1807
Mailing Address - Country:US
Mailing Address - Phone:317-844-5500
Mailing Address - Fax:317-573-4230
Practice Address - Street 1:901 E 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1807
Practice Address - Country:US
Practice Address - Phone:317-844-5500
Practice Address - Fax:317-573-4230
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036083A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000195734OtherBC/BS#
INE18256Medicare UPIN
IN000000195734OtherBC/BS#