Provider Demographics
NPI:1851529952
Name:MACKINNON, BRAD R (MD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:R
Last Name:MACKINNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1400 POTTERY AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3711
Mailing Address - Country:US
Mailing Address - Phone:360-895-5000
Mailing Address - Fax:360-895-5558
Practice Address - Street 1:1400 POTTERY AVE
Practice Address - Street 2:GROUP HEALTH
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3711
Practice Address - Country:US
Practice Address - Phone:360-895-5000
Practice Address - Fax:360-895-5558
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD60111450207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine