Provider Demographics
NPI:1720073067
Name:KNUTH, SANDRA JEAN (DO)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
Last Name:KNUTH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454-1114
Mailing Address - Country:US
Mailing Address - Phone:618-544-3131
Mailing Address - Fax:
Practice Address - Street 1:1000 N ALLEN ST
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-1167
Practice Address - Country:US
Practice Address - Phone:618-544-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360857072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085707Medicaid
IN200144890Medicaid
IL0001732008OtherBCBS OF ILL
ILL79308Medicare ID - Type Unspecified
H19910Medicare UPIN
IL036085707Medicaid