Provider Demographics
NPI:1497713549
Name:MCKENNA, MARTIN JOHN (MD)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:JOHN
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:12550 PROFESSIONAL PARK DRIVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913
Mailing Address - Country:US
Mailing Address - Phone:239-768-2111
Mailing Address - Fax:239-482-4404
Practice Address - Street 1:9911 CORKSCREW ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928
Practice Address - Country:US
Practice Address - Phone:239-768-2111
Practice Address - Fax:239-947-5007
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2013-08-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME66709208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL376808200Medicaid
FL25749Medicare ID - Type Unspecified
FL376808200Medicaid