1316982762 NPI number — JOHN P MCKENZIE III M D INC

Table of content: (NPI 1316982762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316982762 NPI number — JOHN P MCKENZIE III M D INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN P MCKENZIE III M D INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316982762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1510 S CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91204-2500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-247-0346
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
660 W BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91204-1008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-502-9420
Provider Business Practice Location Address Fax Number:
818-243-9605
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCKENZIE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
818-502-9420

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  G71752 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0001X , with the licence number: G71752 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G717520 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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