Provider Demographics
NPI:1477538379
Name:KNUDSEN, JOHN R (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:KNUDSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:314 E MCPHERSON ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-3557
Mailing Address - Country:US
Mailing Address - Phone:660-627-5757
Mailing Address - Fax:660-627-5802
Practice Address - Street 1:600 W. JEFFERSON
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501
Practice Address - Country:US
Practice Address - Phone:660-626-2206
Practice Address - Fax:660-626-2922
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2007-09-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO29333207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE90641Medicare UPIN