MEDICARE: DR. JOHN D. MCKENNA, OPTOMETRIST, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	18003120B	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	220830	OTHER	IN	MEDICARE ID- TYPE UNSPECIFIED

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245645720
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. JOHN D. MCKENNA, OPTOMETRIST, LLC

Provider Business Mailing Address
First Line	:	1511 N POST RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-4247
Country	:	US
Telephone Number	:	317-899-1017
Fax Number	:	317-899-1660

Provider Business Practice Location Address
First Line	:	1511 N POST RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-4247
Country	:	US
Telephone Number	:	317-899-1017
Fax Number	:	317-899-1660

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. JOHN DAVID MCKENNA II
Credential	:	O.D.
Telephone Number	:	317-899-1017

Provider Enumeration Date	:	06/24/2014
Last Update Date	:	06/24/2014

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