Provider Demographics
NPI:1720012073
Name:KNOUS, MELISSA J (OD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:J
Last Name:KNOUS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 N GRANT ST
Mailing Address - Street 2:PO BOX 99
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1459
Mailing Address - Country:US
Mailing Address - Phone:262-692-9000
Mailing Address - Fax:262-692-2797
Practice Address - Street 1:130 MEYER AVE
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:WI
Practice Address - Zip Code:53021-9474
Practice Address - Country:US
Practice Address - Phone:262-692-9000
Practice Address - Fax:262-692-2797
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2016-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2992152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIV06864Medicare UPIN
WI000247319Medicare ID - Type Unspecified