Provider Demographics
NPI:1316135510
Name:DAVID MCKENZIE MD PC
Entity type:Organization
Organization Name:DAVID MCKENZIE MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:BUSINESS MANAGER
Authorized Official - Phone:505-863-9374
Mailing Address - Street 1:1808 E AZTEC AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4946
Mailing Address - Country:US
Mailing Address - Phone:505-863-9374
Mailing Address - Fax:
Practice Address - Street 1:1808 E AZTEC AVE STE 6
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4946
Practice Address - Country:US
Practice Address - Phone:505-863-9374
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11858Medicaid
NM11858Medicaid
NM2133139Medicare PIN