Provider Demographics
NPI:1316272032
Name:MCKINLEY, RICHARD PAUL (OD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:PAUL
Last Name:MCKINLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 MINNIE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3006
Mailing Address - Country:US
Mailing Address - Phone:907-456-7760
Mailing Address - Fax:907-451-7916
Practice Address - Street 1:116 MINNIE ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3006
Practice Address - Country:US
Practice Address - Phone:907-456-7760
Practice Address - Fax:907-451-7916
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKA-131152W00000X
IDO-548152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOD 2131Medicaid