Provider Demographics
NPI:1104825900
Name:MCKENNA, JOHN DAVID II (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:MCKENNA
Suffix:II
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 1:1511 N POST RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4247
Mailing Address - Country:US
Mailing Address - Phone:317-899-1017
Mailing Address - Fax:317-899-1660
Practice Address - Street 1:1511 N POST RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4247
Practice Address - Country:US
Practice Address - Phone:317-899-1017
Practice Address - Fax:317-899-1660
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2012-08-03
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
IN18003120B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00701435OtherMEDICARE RAILROAD
IN1104825900Medicaid
INU90986Medicare UPIN
IN1104825900Medicaid
IN5256660001Medicare NSC