Provider Demographics
NPI:1376819151
Name:MACKINNEY, MIKAEL JUDSON (MD)
Entity type:Individual
Prefix:
First Name:MIKAEL
Middle Name:JUDSON
Last Name:MACKINNEY
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 1:36500 EMERALD COAST PKWY
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-4713
Mailing Address - Country:US
Mailing Address - Phone:850-837-0032
Mailing Address - Fax:850-650-2787
Practice Address - Street 1:36500 EMERALD COAST PKWY
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-4713
Practice Address - Country:US
Practice Address - Phone:850-837-0032
Practice Address - Fax:850-650-2787
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012020815207Q00000X
390200000X
FLME123516207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program