Provider Demographics
NPI:1144218926
Name:KNUDSON, CHARLES MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:KNUDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C MICHAEL
Other - Middle Name:
Other - Last Name:KNUDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:DEPT OF PATHOLOGY
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-335-8147
Mailing Address - Fax:319-335-8453
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:DEPT OF PATHOLOGY
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-335-8147
Practice Address - Fax:319-335-8453
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA32575207ZB0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0180018Medicaid
IA1180018Medicaid
IA33941OtherWELLMARK BCBS
IA46327OtherWELLMARK BCBS
G80243Medicare UPIN
IAP00050280Medicare PIN
IAI9953Medicare PIN
IA46327OtherWELLMARK BCBS
IA1180018Medicaid