MEDICARE: MR. MARK P MCKNIGHT IDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1639131444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK P MCKNIGHT IDC

Provider Business Mailing Address
First Line	:	10227 CLAMAGORO CIR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-3610
Country	:	US
Telephone Number	:	808-227-4518
Fax Number	:

Provider Business Practice Location Address
First Line	:	USS MCCLUSKY FFG 41
Second Line	:
City	:	FPO
State	:	AP
Zip	:	96672-1496
Country	:	US
Telephone Number	:	619-556-4380
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	02/27/2011

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