Provider Demographics
NPI:1619073285
Name:MACKEY, KENT M (OD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:M
Last Name:MACKEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11026 WILMINGTON CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-7539
Mailing Address - Country:US
Mailing Address - Phone:260-436-7530
Mailing Address - Fax:
Practice Address - Street 1:7625 SOUTHTOWN XING
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46816-2517
Practice Address - Country:US
Practice Address - Phone:260-447-3583
Practice Address - Fax:260-441-8276
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1991152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100079460AMedicaid
IN100079460AMedicaid
INT34590Medicare UPIN