Provider Demographics
NPI:1861508095
Name:MCKNELLY, LORENZO DOW (DO)
Entity Type:Individual
Prefix:
First Name:LORENZO
Middle Name:DOW
Last Name:MCKNELLY
Suffix:
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 1:1125 MADISON ST
Mailing Address - Street 2:PO BOX 1128
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-5227
Mailing Address - Country:US
Mailing Address - Phone:573-635-7651
Mailing Address - Fax:573-659-4515
Practice Address - Street 1:1125 MADISON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-5227
Practice Address - Country:US
Practice Address - Phone:573-635-7651
Practice Address - Fax:573-659-4515
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4N29207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO10118C002OtherBC/BS
MO17066OtherGROUP HEALTH PLAN
MO242956837Medicaid
MO105908OtherMERCY HEALTH PLANS
MO04-04436OtherUNITED HEALTHCARE
MO109986OtherBLUE CHOICE
MO110147220OtherRR MEDICARE
MO5833167OtherAETNA
MO04-04436OtherUNITED HEALTHCARE
MO000001217Medicare ID - Type Unspecified