Healthcare Provider Details

I. General information

NPI: 1639131444
Provider Name (Legal Business Name): MARK P MCKNIGHT IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 02/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS MCCLUSKY FFG 41
FPO AP
96672-1496
US

IV. Provider business mailing address

10227 CLAMAGORO CIR
SAN DIEGO CA
92124-3610
US

V. Phone/Fax

Practice location:
  • Phone: 619-556-4380
  • Fax:
Mailing address:
  • Phone: 808-227-4518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: