Provider Demographics
NPI:1801266861
Name:KNUTSON, MYLES (DPM)
Entity type:Individual
Prefix:MR
First Name:MYLES
Middle Name:
Last Name:KNUTSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 B AVE STE S
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3071
Mailing Address - Country:US
Mailing Address - Phone:503-804-7579
Mailing Address - Fax:503-210-0364
Practice Address - Street 1:311 B AVE STE S
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3071
Practice Address - Country:US
Practice Address - Phone:503-804-7579
Practice Address - Fax:503-210-0364
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-03
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
ORDP198427213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty