Provider Demographics
NPI:1003875212
Name:MCKENZIE, LARRY D (DO)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4716 W URBANA ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-6162
Mailing Address - Country:US
Mailing Address - Phone:918-710-4112
Mailing Address - Fax:918-710-4118
Practice Address - Street 1:4716 W URBANA ST STE 200
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-6162
Practice Address - Country:US
Practice Address - Phone:918-710-4112
Practice Address - Fax:918-710-4118
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3116207LP2900X, 207Q00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKF61314Medicare UPIN
OKF61314Medicare UPIN