Provider Demographics
NPI:1558474460
Name:MCKINLEY, O BARRY (MD)
Entity Type:Individual
Prefix:
First Name:O
Middle Name:BARRY
Last Name:MCKINLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BARRY
Other - Middle Name:
Other - Last Name:MCKINLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2999 REGENT ST
Mailing Address - Street 2:225
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2190
Mailing Address - Country:US
Mailing Address - Phone:510-704-7760
Mailing Address - Fax:510-704-7765
Practice Address - Street 1:2999 REGENT ST
Practice Address - Street 2:225
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2190
Practice Address - Country:US
Practice Address - Phone:510-704-7760
Practice Address - Fax:510-704-7765
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG11794207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG11794OtherBLUE CROSS
CA00G117940OtherBLUE SHIELD
CAG11794OtherSTATE LICENSE
CA00G117940Medicaid
CAG11794OtherBLUE CROSS
CAA38446Medicare UPIN
CA200024644Medicare ID - Type UnspecifiedRAILROAD MEDICARE