Provider Demographics
NPI:1548254956
Name:KNUTSON, HEATHER S (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:S
Last Name:KNUTSON
Suffix:
Gender:F
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5727 PROSPERITY CROSSING DR
Practice Address - Street 2:STE 1500
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-2206
Practice Address - Country:US
Practice Address - Phone:704-863-9910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200100285208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1289VOtherBLUE CROSS
SCN0028DMedicaid
NC0283COtherBCBS
NC1548254956Medicaid
NC891289VMedicaid
NC5905198Medicaid
NC89-0283CMedicaid
1289VOtherBLUE CROSS
NC1548254956Medicaid
SCN0028DMedicaid
NC2286158Medicare PIN