Provider Demographics
NPI:1194719799
Name:MCKINLEY, LAURENCE MERCER (MD)
Entity type:Individual
Prefix:
First Name:LAURENCE
Middle Name:MERCER
Last Name:MCKINLEY
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:PO BOX 28199
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92198-0199
Mailing Address - Country:US
Mailing Address - Phone:760-489-2379
Mailing Address - Fax:760-489-8106
Practice Address - Street 1:355 E GRAND AVE
Practice Address - Street 2:SUITE 1-2
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3313
Practice Address - Country:US
Practice Address - Phone:760-489-2379
Practice Address - Fax:760-489-8106
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30927207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A309270Medicaid
FS425ZMedicare PIN
CA00A309270Medicaid