Provider Demographics
NPI:1285666891
Name:KNUDSON, HOMER E (MD)
Entity Type:Individual
Prefix:
First Name:HOMER
Middle Name:E
Last Name:KNUDSON
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 1:8308 OLD COURTHOUSE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3863
Mailing Address - Country:US
Mailing Address - Phone:703-790-9440
Mailing Address - Fax:703-790-5359
Practice Address - Street 1:8308 OLD COURTHOUSE RD
Practice Address - Street 2:SUITE A
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3863
Practice Address - Country:US
Practice Address - Phone:703-790-9440
Practice Address - Fax:703-790-5359
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23301174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4087376OtherAETNA PPO
VA07-00455OtherUNITED HEALTHCARE PIN
VA088399OtherANTHEM PPO/HEALTHKEEPERS
VA0785845OtherAETNA HMO
VA10316OtherUNICARE
VA4087OtherCAREFIRST PPO/ BLUECHOICE
VA6260730Medicaid
VA99214OtherGUARDIAN
VA1463350004OtherCIGNA PIN
VA4087OtherBLUECROSS BLUESHIELD PPO
VA27007OtherOPTIMUMCHOICE/MAMSI/MDIPA
VA6260730Medicaid