Provider Demographics
NPI:1558351304
Name:MCKENNA, ROBERT (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7517 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6537
Mailing Address - Country:US
Mailing Address - Phone:718-779-1222
Mailing Address - Fax:
Practice Address - Street 1:7517 37TH AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6537
Practice Address - Country:US
Practice Address - Phone:718-779-1222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00751157Medicaid