Provider Demographics
NPI:1124258777
Name:KNUDSEN, CHRISTOPHER D (DO)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:D
Last Name:KNUDSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:2115 S FREMONT AVE
Practice Address - Street 2:SUITE 3300
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2239
Practice Address - Country:US
Practice Address - Phone:417-820-5200
Practice Address - Fax:417-820-5220
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO.1164207R00000X
MO2015021892207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1124258777Medicaid
MO132680705Medicare PIN