Healthcare Provider Details

I. General information

NPI: 1306935523
Provider Name (Legal Business Name): DUANE KNOWLES OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 W 5TH S
BOUNTIFUL UT
84010-6232
US

IV. Provider business mailing address

1901 W PARKWAY BLVD
SALT LAKE CITY UT
84119
US

V. Phone/Fax

Practice location:
  • Phone: 801-292-0479
  • Fax: 801-292-7019
Mailing address:
  • Phone: 801-886-2020
  • Fax: 801-954-0054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2773469934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: