Provider Demographics
NPI:1972642635
Name:KNICK, PAUL D (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:D
Last Name:KNICK
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1229 E SEMINOLE ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2227
Practice Address - Country:US
Practice Address - Phone:471-820-9393
Practice Address - Fax:417-820-3758
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02929152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO108510OtherMO BLUE SHIELD
MO318604006Medicaid
AR81596OtherARK BLUE SHIELD
U64046Medicare UPIN
MO000091177Medicare PIN
MO261703230Medicare PIN