Provider Demographics
NPI:1083791644
Name:K. D. MACKNET, M.D., INC.
Entity Type:Organization
Organization Name:K. D. MACKNET, M.D., INC.
Other - Org Name:LOMA LINDA DERMATOLOGY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:D
Authorized Official - Last Name:MACKNET
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:909-796-0224
Mailing Address - Street 1:25815 BARTON ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3894
Mailing Address - Country:US
Mailing Address - Phone:909-796-0224
Mailing Address - Fax:909-796-0225
Practice Address - Street 1:25815 BARTON ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3894
Practice Address - Country:US
Practice Address - Phone:909-796-0224
Practice Address - Fax:909-796-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA63594Medicaid
CA05D0687031OtherCLIA
1083791644OtherNPI
1083791644OtherNPI
CAA40349Medicare UPIN
CA05D0687031OtherCLIA
CAA63594Medicaid
ZZZ25762ZMedicare ID - Type UnspecifiedMEDICARE
OOA635942Medicare ID - Type UnspecifiedMEDICARE