Provider Demographics
NPI:1851356109
Name:KNUDSON, JAMES LEONARD (DPM)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:LEONARD
Last Name:KNUDSON
Suffix:
Gender:M
Credentials:DPM
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 368
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-0368
Mailing Address - Country:US
Mailing Address - Phone:310-994-9376
Mailing Address - Fax:310-202-8291
Practice Address - Street 1:9808 VENICE BLVD STE 600
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-6807
Practice Address - Country:US
Practice Address - Phone:310-876-1579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2159213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E21590Medicaid
CAT19166Medicare UPIN
CA000E21590Medicaid