Healthcare Provider Details

I. General information

NPI: 1730276247
Provider Name (Legal Business Name): CLARK JON KNUTSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 BRIDGE STREET
PLATTSBURGH NY
12901
US

IV. Provider business mailing address

151 BRIDGE STREET
PLATTSBURGH NY
12901
US

V. Phone/Fax

Practice location:
  • Phone: 518-561-7337
  • Fax: 518-561-1335
Mailing address:
  • Phone: 518-561-7337
  • Fax: 518-561-1335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35C001716
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2128611
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35C001716
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: