Basic Information
| Provider Information | |||||||||
| NPI: | 1306935523 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNOWLES | ||||||||
| FirstName: | DUANE | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 W PARKWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8018862020 | ||||||||
| FaxNumber: | 8019540054 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 W 5TH S | ||||||||
| Address2: | |||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840106232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012920479 | ||||||||
| FaxNumber: | 8012927019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 09/19/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2773469934 | UT | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1306935523 | 05 | UT | MEDICAID | 000009430 | 01 | UT | MEDICARE STORE #9 PTAN | OTHER | 000009542 | 01 | UT | MEDICARE STORE #11 PTAN | OTHER | 009037404 | 01 | UT | MEDICARE | OTHER | 000090374 | 01 | UT | MEDICARE STORE #10 PTAN | OTHER | 009602004 | 01 | UT | MEDICARE | OTHER |