Provider Demographics
NPI:1306935523
Name:KNOWLES, DUANE (OD)
Entity type:Individual
Prefix:
First Name:DUANE
Middle Name:
Last Name:KNOWLES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 W PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119
Mailing Address - Country:US
Mailing Address - Phone:801-886-2020
Mailing Address - Fax:801-954-0054
Practice Address - Street 1:140 W 5TH S
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6232
Practice Address - Country:US
Practice Address - Phone:801-292-0479
Practice Address - Fax:801-292-7019
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2773469934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1306935523Medicaid
UT000009430OtherMEDICARE STORE #9 PTAN
UT000009542OtherMEDICARE STORE #11 PTAN
UT009037404OtherMEDICARE
UT000090374OtherMEDICARE STORE #10 PTAN
UT009602004OtherMEDICARE
UT009602004OtherMEDICARE
UT009037404OtherMEDICARE
UT0618950017Medicare NSC
UT005701504Medicare PIN
UT009922004Medicare PIN
UT009430004Medicare PIN
UT000009430OtherMEDICARE STORE #9 PTAN
UT0618950009Medicare NSC
UT0618950010Medicare NSC
UT0618950012Medicare NSC
UT0618950019Medicare NSC
UT0618950007Medicare NSC
UT009926004Medicare ID - Type Unspecified
UT000090374OtherMEDICARE STORE #10 PTAN
UT000009542OtherMEDICARE STORE #11 PTAN
UT004473004Medicare ID - Type Unspecified
UT009841004Medicare ID - Type Unspecified
UT1306935523Medicaid