Provider Demographics
NPI:1568790046
Name:KNUTSON, MELISSA SUE (DO)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:KNUTSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 E BABCOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-4710
Mailing Address - Country:US
Mailing Address - Phone:406-585-0022
Mailing Address - Fax:406-585-0032
Practice Address - Street 1:316 E BABCOCK ST
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-4710
Practice Address - Country:US
Practice Address - Phone:406-585-0022
Practice Address - Fax:406-585-0032
Is Sole Proprietor?:No
Enumeration Date:2009-11-23
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34009672207Q00000X
ORDO157503207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV10024004OtherWV BWC
OH3029332OtherMOLINA
OH3029332Medicaid
WV3810017114Medicaid
OH3029332OtherMOLINA