Provider Demographics
NPI:1528039278
Name:MCKINNIS, DEBORAH SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:SUE
Last Name:MCKINNIS
Suffix:
Gender:F
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:PO BOX 10549
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-0549
Mailing Address - Country:US
Mailing Address - Phone:727-824-8181
Mailing Address - Fax:727-824-8134
Practice Address - Street 1:1344 22ND ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-2744
Practice Address - Country:US
Practice Address - Phone:727-824-8181
Practice Address - Fax:727-824-8134
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57321208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL053248700Medicaid
E92702Medicare UPIN
12552Medicare ID - Type Unspecified