Provider Demographics
NPI:1891773552
Name:KNICKREHM, JON FRANCIS (DO)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:FRANCIS
Last Name:KNICKREHM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:10201 AVALON LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913
Mailing Address - Country:US
Mailing Address - Phone:239-768-7171
Mailing Address - Fax:239-939-0151
Practice Address - Street 1:12511 WORLD PLAZA LN BLDG 50
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3991
Practice Address - Country:US
Practice Address - Phone:239-939-2622
Practice Address - Fax:239-939-0151
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO-596207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276018500Medicaid
56478OtherBC BS FL
FLP00343579OtherRAILROAD MEDICARE
591783920OtherEIN
U7777ZMedicare PIN