Provider Demographics
NPI:1760462352
Name:KNUTSON, THOMAS J (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:KNUTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 1ST ST
Mailing Address - Street 2:
Mailing Address - City:OCONTO
Mailing Address - State:WI
Mailing Address - Zip Code:54153-1117
Mailing Address - Country:US
Mailing Address - Phone:920-835-1144
Mailing Address - Fax:920-835-1145
Practice Address - Street 1:103 1ST ST
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-1117
Practice Address - Country:US
Practice Address - Phone:920-835-1144
Practice Address - Fax:920-835-1145
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1467583278OtherOMC NPI
WI30674900Medicaid
WI080193662OtherRAILROAD MEDICARE
WI1851477913OtherCMH NPI
WI11014110Medicaid
WI080193662OtherRAILROAD MEDICARE
WI30674900Medicaid
WI1467583278OtherOMC NPI
WIB54227Medicare UPIN