Provider Demographics
NPI:1578721783
Name:KNUTSON, MELISSA C (DO)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:C
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1351 RONALD REAGAN PKWY STE A
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-6764
Practice Address - Country:US
Practice Address - Phone:317-217-2919
Practice Address - Fax:317-217-2916
Is Sole Proprietor?:No
Enumeration Date:2008-05-26
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003922207R00000X
NC2010-00476208M00000X
IN02003922A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201032610Medicaid
IN000000729675OtherANTHEM PIN
IN000000729675OtherANTHEM PIN
INP01035493Medicare PIN