Provider Demographics
NPI:1518905041
Name:MCKINLEY, DOMINIC W (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:W
Last Name:MCKINLEY
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 1:1915 LENDEW ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7033
Mailing Address - Country:US
Mailing Address - Phone:336-275-3325
Mailing Address - Fax:336-275-5346
Practice Address - Street 1:1915 LENDEW ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7033
Practice Address - Country:US
Practice Address - Phone:336-275-3325
Practice Address - Fax:336-275-5346
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801388207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891275UMedicaid
NC891275UMedicaid
H44947Medicare UPIN