Provider Demographics
NPI:1174578827
Name:MCKISSOCK, JOHN K (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:K
Last Name:MCKISSOCK
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Gender:M
Credentials:MD
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Mailing Address - Street 1:3440 LOMITA BLVD
Mailing Address - Street 2:SUITE #150
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4863
Mailing Address - Country:US
Mailing Address - Phone:310-257-9425
Mailing Address - Fax:310-530-2146
Practice Address - Street 1:3440 LOMITA BLVD
Practice Address - Street 2:SUITE #150
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4863
Practice Address - Country:US
Practice Address - Phone:310-257-9425
Practice Address - Fax:310-530-2146
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2014-08-12
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Provider Licenses
StateLicense IDTaxonomies
CAG84015208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G19200Medicare UPIN