Provider Demographics
NPI:1962409938
Name:KNUTSON, THOMAS R (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
Last Name:KNUTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15611 POMERADO RD
Mailing Address - Street 2:FIFTH FLOOR
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2437
Mailing Address - Country:US
Mailing Address - Phone:858-673-2574
Mailing Address - Fax:858-618-1523
Practice Address - Street 1:1955 CITRACADO PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92029-4110
Practice Address - Country:US
Practice Address - Phone:760-743-4789
Practice Address - Fax:760-743-4779
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2016-03-24
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
CAG50268207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG50268OtherMEDICAL LICENSE
CA1962409938OtherNPI NUMBER
CA1962409938Medicaid
CA1962409938Medicaid
CA00G502680Medicaid
CAG50268OtherMEDICAL LICENSE
CAA51623Medicare UPIN
CAWG50268BMedicare ID - Type UnspecifiedPPIN
CA1962409938OtherNPI NUMBER