Provider Demographics
NPI:1396871547
Name:KNUTSON, ROBERT (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
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 1:122 1ST AVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4803
Mailing Address - Country:US
Mailing Address - Phone:406-698-0290
Mailing Address - Fax:406-698-0290
Practice Address - Street 1:122 1ST AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4803
Practice Address - Country:US
Practice Address - Phone:406-698-0290
Practice Address - Fax:406-698-0290
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT547152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0484194Medicaid
MTT39573Medicare UPIN
MT0484194Medicaid