Provider Demographics
NPI:1124188511
Name:KNOWLES, ANTONIO LAVALE (DPM)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:LAVALE
Last Name:KNOWLES
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5362 ESTATE OFFICE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3635
Mailing Address - Country:US
Mailing Address - Phone:901-537-0078
Mailing Address - Fax:901-537-0096
Practice Address - Street 1:5362 ESTATE OFFICE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3635
Practice Address - Country:US
Practice Address - Phone:901-537-0078
Practice Address - Fax:901-537-0096
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN581213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3353517Medicaid
TNU87343Medicare UPIN
TN3353517Medicare ID - Type Unspecified