Provider Demographics
NPI:1740400274
Name:NICK KNUTSON MD, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:NICK KNUTSON MD, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-631-0481
Mailing Address - Street 1:8100 S WALKER AVE
Mailing Address - Street 2:BUILDING 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:
Practice Address - Street 1:8100 S WALKER AVE
Practice Address - Street 2:BUILDING 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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10530207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKJ=========Medicaid
OK=========001OtherBLUE CROSS BLUE SHIELD
OK=========001OtherBLUE CROSS BLUE SHIELD
446486963Medicare ID - Type Unspecified