Provider Demographics
NPI:1821061326
Name:MCKENNA, MICHAEL DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DANIEL
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 DELHI ST
Mailing Address - Street 2:STE 4100
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-6358
Mailing Address - Country:US
Mailing Address - Phone:563-557-5900
Mailing Address - Fax:563-557-5905
Practice Address - Street 1:1500 DELHI ST
Practice Address - Street 2:STE 4100
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-6358
Practice Address - Country:US
Practice Address - Phone:563-557-5900
Practice Address - Fax:563-557-5905
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33868174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2188276Medicaid
IA55734OtherINDIVIDUAL WELLMARK NUMBE
IA1821061326OtherNPI
IA13252OtherDEANHEALTHCARE NUMBER
IAIA0108OtherJOHN DEERE HEALTH NUMBER
IA55321Medicare PIN
IA55734OtherINDIVIDUAL WELLMARK NUMBE