Provider Demographics
NPI:1750307559
Name:KNELSON, MARK HENRY (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HENRY
Last Name:KNELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4020 WESTCHASE BLVD
Mailing Address - Street 2:SUITE 390
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-3938
Mailing Address - Country:US
Mailing Address - Phone:919-834-2767
Mailing Address - Fax:919-834-0234
Practice Address - Street 1:4420 LAKE BOONE TRL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7505
Practice Address - Country:US
Practice Address - Phone:919-784-3023
Practice Address - Fax:919-784-3497
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC389972085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8949741Medicaid
NC8949741Medicaid
E46890Medicare UPIN