Provider Demographics
NPI:1457326571
Name:MCKINNON, MARK STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:MCKINNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7771 STATE HIGHWAY 153
Mailing Address - Street 2:
Mailing Address - City:WINTERS
Mailing Address - State:TX
Mailing Address - Zip Code:79567-7350
Mailing Address - Country:US
Mailing Address - Phone:325-754-1317
Mailing Address - Fax:325-754-1208
Practice Address - Street 1:7771 STATE HIGHWAY 153
Practice Address - Street 2:
Practice Address - City:WINTERS
Practice Address - State:TX
Practice Address - Zip Code:79567-7350
Practice Address - Country:US
Practice Address - Phone:325-754-1317
Practice Address - Fax:325-754-1208
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8827207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100168190AMedicaid
G53128Medicare UPIN
OK249341141Medicare ID - Type Unspecified