Provider Demographics
NPI:1710960299
Name:MACKEY, JOHN K (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:K
Last Name:MACKEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:KEVIN
Other - Last Name:MACKEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:12021 WILSHIRE BLVD
Mailing Address - Street 2:#888
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1206
Mailing Address - Country:US
Mailing Address - Phone:310-709-4631
Mailing Address - Fax:
Practice Address - Street 1:12021 WILSHIRE BLVD
Practice Address - Street 2:#888
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1206
Practice Address - Country:US
Practice Address - Phone:310-709-4631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG463952085N0700X, 2085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A50374Medicare UPIN