Provider Demographics
NPI:1669431706
Name:MCKENNA, ROBERT W (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
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:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-0624
Mailing Address - Fax:214-645-0078
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-645-0624
Practice Address - Fax:214-645-0078
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9936207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126394903Medicaid
81P236Medicare ID - Type Unspecified
TX126394903Medicaid