Healthcare Provider Details

I. General information

NPI: 1760462352
Provider Name (Legal Business Name): THOMAS J. KNUTSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 1ST ST
OCONTO WI
54153-1117
US

IV. Provider business mailing address

103 1ST ST
OCONTO WI
54153-1117
US

V. Phone/Fax

Practice location:
  • Phone: 920-835-1144
  • Fax: 920-835-1145
Mailing address:
  • Phone: 920-835-1144
  • Fax: 920-835-1145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25152
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: