Provider Demographics
NPI:1730276247
Name:KNUTSON, CLARK JON (MD)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:JON
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 1:151 BRIDGE STREET
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901
Mailing Address - Country:US
Mailing Address - Phone:518-561-7337
Mailing Address - Fax:518-561-1335
Practice Address - Street 1:151 BRIDGE STREET
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901
Practice Address - Country:US
Practice Address - Phone:518-561-7337
Practice Address - Fax:518-561-1335
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35C001716208000000X, 208M00000X
NY2128611208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000490822003OtherBSNNY
OH0054654Medicaid
NY01908429Medicaid