Provider Demographics
NPI:1326323502
Name:DR. JOHN D. MCKENNA OPTOMETRIST, LLC
Entity Type:Organization
Organization Name:DR. JOHN D. MCKENNA OPTOMETRIST, LLC
Other - Org Name:MCKENNA FAMILY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-899-1017
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003120B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1104825900Medicaid
INP00701435OtherRAILROAD MEDICARE
IN220830OtherMEDICARE ID - TYPE UNSPECIFIED
IN1104825900Medicaid
IN5256660001Medicare NSC