Healthcare Provider Details

I. General information

NPI: 1841472479
Provider Name (Legal Business Name): JOHN D MACKENNEY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6550 N WICKHAM RD STE 4
MELBOURNE FL
32940-2038
US

IV. Provider business mailing address

6550 N WICKHAM RD STE 4
MELBOURNE FL
32940-2038
US

V. Phone/Fax

Practice location:
  • Phone: 321-259-4268
  • Fax:
Mailing address:
  • Phone: 321-259-4268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3043
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN DAVID MACKENNEY
Title or Position: OWNER PHYSICIAN
Credential: DPM
Phone: 321-259-4268