Provider Demographics
NPI:1285818096
Name:JOHN K MCKISSOCK MD
Entity Type:Organization
Organization Name:JOHN K MCKISSOCK MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCKISSOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-257-9425
Mailing Address - Street 1:3440 LOMITA BLVD
Mailing Address - Street 2:150
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4801
Mailing Address - Country:US
Mailing Address - Phone:310-257-9425
Mailing Address - Fax:310-530-2146
Practice Address - Street 1:3440 LOMITA BLVD
Practice Address - Street 2:150
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4801
Practice Address - Country:US
Practice Address - Phone:310-257-9425
Practice Address - Fax:310-530-2146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84015174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G840150Medicaid
CAG19200Medicare UPIN