Provider Demographics
NPI:1982679114
Name:KNUTSON, ERIC H (OD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:H
Last Name:KNUTSON
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 1:1505 NW HARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-5816
Mailing Address - Country:US
Mailing Address - Phone:541-754-6222
Mailing Address - Fax:541-757-2055
Practice Address - Street 1:1505 NW HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5816
Practice Address - Country:US
Practice Address - Phone:541-754-6222
Practice Address - Fax:541-757-2055
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1046ATI152W00000X, 152WC0802X, 152WP0200X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1046ATIOtherPIN#
OR055502001OtherBLUE CROSS
OR0664890001Medicare NSC
ORR109919Medicare PIN
OR1046ATIOtherPIN#