Provider Demographics
NPI:1942210117
Name:MCKENNA, ROBERT JOSEPH JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOSEPH
Last Name:MCKENNA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:400 S WINDSOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-4714
Mailing Address - Country:US
Mailing Address - Phone:424-272-0337
Mailing Address - Fax:310-861-5508
Practice Address - Street 1:2121 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2303
Practice Address - Country:US
Practice Address - Phone:310-829-8618
Practice Address - Fax:310-829-8607
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG39081208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G390810Medicaid
CA00G390810Medicaid
CA00G390810Medicaid