Provider Demographics
NPI:1134114390
Name:KNOLL, WAYNE K (DPM)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:K
Last Name:KNOLL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:WAYNE
Other - Middle Name:KARL
Other - Last Name:KNOLL
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:128 LUBRONO DR
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7028
Mailing Address - Country:US
Mailing Address - Phone:410-535-0620
Mailing Address - Fax:410-535-0802
Practice Address - Street 1:128 LUBRONO DR
Practice Address - Street 2:SUITE 102
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7028
Practice Address - Country:US
Practice Address - Phone:410-535-0620
Practice Address - Fax:410-535-0802
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01252213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD017203101Medicaid
MDU84078Medicare UPIN
MD514RMedicare ID - Type Unspecified
MD5473430001Medicare NSC