Provider Demographics
NPI:1639131444
Name:MCKNIGHT, MARK P (IDC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:P
Last Name:MCKNIGHT
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10227 CLAMAGORO CIR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3610
Mailing Address - Country:US
Mailing Address - Phone:808-227-4518
Mailing Address - Fax:
Practice Address - Street 1:USS MCCLUSKY FFG 41
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96672-1496
Practice Address - Country:US
Practice Address - Phone:619-556-4380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2011-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman