Provider Demographics
NPI:1841472479
Name:JOHN D MACKENNEY PA
Entity type:Organization
Organization Name:JOHN D MACKENNEY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MACKENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:321-259-4268
Mailing Address - Street 1:6550 N WICKHAM RD STE 4
Mailing Address - Street 2:
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:
Practice Address - Street 1:6550 N WICKHAM RD STE 4
Practice Address - Street 2:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
FLPO3043213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340376900Medicaid
FLU96263Medicare UPIN
FL5013550001Medicare NSC
FL340376900Medicaid