Provider Demographics
NPI:1124020383
Name:KNOLMAYER, BRUCE ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ROBERT
Last Name:KNOLMAYER
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 1:19231 MONTGOMERY VILLAGE AVE
Mailing Address - Street 2:STE D21
Mailing Address - City:MONTGOMRY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-5034
Mailing Address - Country:US
Mailing Address - Phone:301-977-6777
Mailing Address - Fax:301-977-0108
Practice Address - Street 1:19231 MONTGOMERY VILLAGE AVE
Practice Address - Street 2:STE D21
Practice Address - City:MONTGOMRY VILLAGE
Practice Address - State:MD
Practice Address - Zip Code:20886-5034
Practice Address - Country:US
Practice Address - Phone:301-977-6777
Practice Address - Fax:301-977-0108
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2007-01-22
Provider Licenses
StateLicense IDTaxonomies
MDD0051684207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KN951526Medicare ID - Type Unspecified
G56790Medicare UPIN