Provider Demographics
NPI:1477631885
Name:MCKINNON, WILLIAM MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MARTIN
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 1:550 PEACHTREE ST NE
Mailing Address - Street 2:SUITE 1085
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-2232
Mailing Address - Country:US
Mailing Address - Phone:404-681-3190
Mailing Address - Fax:404-681-3193
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:SUITE 1085
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2232
Practice Address - Country:US
Practice Address - Phone:404-681-3190
Practice Address - Fax:404-681-3193
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA172332086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
581376411OtherCIGNA
770002368OtherMEDICARE RR
GA214476OtherBLUE CROSS BLUE SHIELD
GA578663OtherAETNA
GA00178725BMedicaid
1705837Other1ST HEALTH
770002368OtherMEDICARE RR