Provider Demographics
NPI:1609813674
Name:KNACKSTEDT, CAMERON D (DO)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:D
Last Name:KNACKSTEDT
Suffix:
Gender:M
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:PO BOX 665
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:NE
Mailing Address - Zip Code:68920-0665
Mailing Address - Country:US
Mailing Address - Phone:308-928-2103
Mailing Address - Fax:308-928-2560
Practice Address - Street 1:715 BROWN ST
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:NE
Practice Address - Zip Code:68920-2132
Practice Address - Country:US
Practice Address - Phone:308-928-2103
Practice Address - Fax:308-928-2560
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0516910207Q00000X
NE802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS102291OtherBCBS
KS100229260HMedicaid
KS100229260EMedicaid
NE10025988300Medicaid
KS100229260GMedicaid
NE10025988200Medicaid
NE10025988200Medicaid
KS100229260GMedicaid
KS100229260HMedicaid