Healthcare Provider Details

I. General information

NPI: 1376819151
Provider Name (Legal Business Name): MIKAEL JUDSON MACKINNEY M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16500 PANAMA CITY BEACH PKWY
PANAMA CITY BEACH FL
32413-2217
US

IV. Provider business mailing address

16500 PANAMA CITY BEACH PKWY
PANAMA CITY BEACH FL
32413-2217
US

V. Phone/Fax

Practice location:
  • Phone: 913-940-5169
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME123516
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2012020815
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: