1154364743 NPI number — GARY KNOWLES OD

Table of content: GARY KNOWLES OD (NPI 1154364743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154364743 NPI number — GARY KNOWLES OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KNOWLES
Provider First Name:
GARY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154364743
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
506 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97338-1915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-623-9233
Provider Business Mailing Address Fax Number:
503-623-9233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
506 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97338-1915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-623-9233
Provider Business Practice Location Address Fax Number:
503-623-9233
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1547T , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 279018 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0310568863 . This is a "EYE MED" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 022775000 . This is a "BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 7072090 . This is a "AETNA" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 93093 . This is a "LIFEWISE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 002118501001 . This is a "CATERPILLAR" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 93082710497338 . This is a "TRICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 31107 . This is a "UNITED MEDICAL RESOURCES" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 93029 . This is a "PACIFIC SOURCE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: O000790187 . This is a "MUTUAL OF OMAHA" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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