Provider Demographics
NPI:1316056419
Name:MCKENNA, DWIGHT LAWRENCE (MD)
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:LAWRENCE
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 1:4433 TCHOUPITOULAS ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-1554
Mailing Address - Country:US
Mailing Address - Phone:504-899-1056
Mailing Address - Fax:504-899-1954
Practice Address - Street 1:1827 GENTILLY BLVD
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-2051
Practice Address - Country:US
Practice Address - Phone:504-943-1923
Practice Address - Fax:504-943-1933
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03347R174400000X
LAMD03347R208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAUP4206OtherUNITED HEALTHCARE
LA1129267Medicaid
LAF4229OtherBLUE CROSS/BLUE SHIELD
LAUP4206OtherUNITED HEALTHCARE
LAF4229OtherBLUE CROSS/BLUE SHIELD