Provider Demographics
NPI:1447303755
Name:KNOTTS, MARJORIE J (OD)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:J
Last Name:KNOTTS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6326 RUCKER RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-4889
Mailing Address - Country:US
Mailing Address - Phone:317-259-4234
Mailing Address - Fax:317-259-1538
Practice Address - Street 1:6326 RUCKER RD
Practice Address - Street 2:SUITE C
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4889
Practice Address - Country:US
Practice Address - Phone:317-259-4234
Practice Address - Fax:317-259-1538
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002141B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INT35062Medicare UPIN
IN274830AMedicare ID - Type Unspecified