Provider Demographics
NPI:1942364823
Name:KNOX, KENNETH (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:KNOX
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 WOODCLIFF CT
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-2037
Mailing Address - Country:US
Mailing Address - Phone:864-963-5937
Mailing Address - Fax:
Practice Address - Street 1:309 SE MAIN ST
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-2653
Practice Address - Country:US
Practice Address - Phone:864-963-4933
Practice Address - Fax:864-963-4933
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC594T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC322168Medicaid
SC322168Medicaid