Provider Demographics
NPI:1558328559
Name:KNUTSON, NICKEY GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:NICKEY
Middle Name:GLENN
Last Name:KNUTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8100 S WALKER AVE
Mailing Address - Street 2:BLDG A, SUITE 230
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-9402
Mailing Address - Country:US
Mailing Address - Phone:405-631-0481
Mailing Address - Fax:405-631-9025
Practice Address - Street 1:8100 S WALKER AVE
Practice Address - Street 2:BLDG A, SUITE 230
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9402
Practice Address - Country:US
Practice Address - Phone:405-631-0481
Practice Address - Fax:405-631-9025
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK10530207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731135951001OtherBLUE CROSS/BLUE SHIELD
OKD34905Medicare UPIN