Healthcare Provider Details

I. General information

NPI: 1497713549
Provider Name (Legal Business Name): MARTIN JOHN MCKENNA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9911 CORKSCREW ROAD SUITE 101
ESTERO FL
33928
US

IV. Provider business mailing address

12550 PROFESSIONAL PARK DRIVE SUITE 11
FORT MYERS FL
33913
US

V. Phone/Fax

Practice location:
  • Phone: 239-768-2111
  • Fax: 239-947-5007
Mailing address:
  • Phone: 239-768-2111
  • Fax: 239-482-4404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME66709
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: