Provider Demographics
NPI:1396715173
Name:KNUTH, JOHN GERARD (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GERARD
Last Name:KNUTH
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 1:535 SOUTH MONROE AVENUE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4096
Mailing Address - Country:US
Mailing Address - Phone:920-435-9511
Mailing Address - Fax:920-435-9383
Practice Address - Street 1:535 SOUTH MONROE AVENUE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4096
Practice Address - Country:US
Practice Address - Phone:920-435-9511
Practice Address - Fax:920-435-9383
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2308152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38581000Medicaid
WI053309OtherAMERICAN OPTOMET ASSOC
WIMK0095744OtherDEA
WI87007EYEAMedicare ID - Type Unspecified
WI38581000Medicaid