Provider Demographics
NPI:1770531774
Name:MACKENNEY, JOHN DAVID (DPM)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:MACKENNEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6550 N WICKHAM RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-2038
Mailing Address - Country:US
Mailing Address - Phone:321-259-4268
Mailing Address - Fax:321-259-4369
Practice Address - Street 1:6550 N WICKHAM RD
Practice Address - Street 2:SUITE 4
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2038
Practice Address - Country:US
Practice Address - Phone:321-259-4268
Practice Address - Fax:321-259-4369
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPO3043213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
5013550001Medicare NSC
FLK5227Medicare ID - Type Unspecified
FLU96263Medicare UPIN
FL65811ZMedicare PIN