Healthcare Provider Details

I. General information

NPI: 1750340527
Provider Name (Legal Business Name): MICHAEL WALDEMAR KNUDSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 TILGHMAN DR
DUNN NC
28334-5510
US

IV. Provider business mailing address

802 TILGHMAN DR
DUNN NC
28334-5510
US

V. Phone/Fax

Practice location:
  • Phone: 910-892-4248
  • Fax: 910-892-4461
Mailing address:
  • Phone: 910-892-4248
  • Fax: 910-892-4461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number116821
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35683
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8949781
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: