Provider Demographics
NPI:1326017955
Name:KNUTSON, RENEE J (MD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:J
Last Name:KNUTSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-7241
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:3920 ST FRANCIS WAY STE 110
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4917
Practice Address - Country:US
Practice Address - Phone:765-428-5990
Practice Address - Fax:765-428-5896
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01045000A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10783508OtherCAQH
INP00192247OtherMEDICARE RAILROAD NUMBER
IN200168150Medicaid
IN471400091OtherMEDICARE
IN000000324386OtherANTHEM PROVIDER NUMBER
IN000000324386OtherANTHEM PROVIDER NUMBER