Provider Demographics
NPI:1639104391
Name:MACKNET, CATHY A (MD)
Entity Type:Individual
Prefix:DR
First Name:CATHY
Middle Name:A
Last Name:MACKNET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:CATHY
Other - Middle Name:ANNE
Other - Last Name:MACKNET KASNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:25815 BARTON RD
Mailing Address - Street 2:STE 101
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3893
Mailing Address - Country:US
Mailing Address - Phone:909-796-0224
Mailing Address - Fax:909-796-0225
Practice Address - Street 1:25815 BARTON RD
Practice Address - Street 2:STE 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
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89870207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1639104391Medicare UPIN