Provider Demographics
NPI:1639222565
Name:ROBERT J. MCKENNA JR. MD, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ROBERT J. MCKENNA JR. MD, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:310-652-0530
Mailing Address - Street 1:8635 W THIRD STREET
Mailing Address - Street 2:NO 975W
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-6101
Mailing Address - Country:US
Mailing Address - Phone:310-652-0530
Mailing Address - Fax:310-652-9936
Practice Address - Street 1:8635 W THIRD STREET
Practice Address - Street 2:NO 975W
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-6101
Practice Address - Country:US
Practice Address - Phone:310-652-0530
Practice Address - Fax:310-652-9936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39081174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0091070Medicaid
CAGR0091070Medicaid