Provider Demographics
NPI:1538191879
Name:MCKENNA, MATTHEW JOHN (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 N CROATAN HWY
Mailing Address - Street 2:
Mailing Address - City:KILL DEVIL HILLS
Mailing Address - State:NC
Mailing Address - Zip Code:27948-9200
Mailing Address - Country:US
Mailing Address - Phone:252-261-9940
Mailing Address - Fax:252-261-9087
Practice Address - Street 1:3102 N CROATAN HWY
Practice Address - Street 2:
Practice Address - City:KILL DEVIL HILLS
Practice Address - State:NC
Practice Address - Zip Code:27948-9200
Practice Address - Country:US
Practice Address - Phone:252-261-9940
Practice Address - Fax:252-261-9087
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200500680207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1397COtherBCBS
P00276854OtherRR MEDICARE
NC5902017Medicaid
NC1397COtherBCBS
2042068Medicare ID - Type Unspecified