Provider Demographics
NPI:1750310629
Name:MCKINNEY, JOHN RONALD JR (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RONALD
Last Name:MCKINNEY
Suffix:JR
Gender:M
Credentials:DO
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 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-531-4262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119484207P00000X
TXL4566207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0074PTOtherBCBS
TX8X8169OtherBCBS
TX154641808Medicaid
TX154641809Medicaid
TXTIN PLUS 044OtherTRICARE MFH WINNSBORO LOCATION
TX154641813Medicaid
TXTIN PLUS 015OtherTRICARE MFH LOCATION
TX154641810Medicaid
TX750818167022OtherTRICARE
TXTIN PLUS 005OtherTRICARE JV LOCATION
TX0074PTOtherBCBS
TX750818167022OtherTRICARE
TXTIN PLUS 015OtherTRICARE MFH LOCATION
TX154641809Medicaid
TX8L1019Medicare Oscar/Certification