Provider Demographics
NPI:1053311910
Name:MC KENZIE, EARL III (MD)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:
Last Name:MC KENZIE
Suffix:III
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4646
Mailing Address - Country:US
Mailing Address - Phone:850-216-0100
Mailing Address - Fax:
Practice Address - Street 1:1300 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4646
Practice Address - Country:US
Practice Address - Phone:850-216-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME17224207RC0000X
GA012109207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00000OtherBCBSFL
FL00000OtherHUMANA CHOICE CARE
FL00000OtherSOUTHCARE
FL00000OtherUNIVERSAL HEALTH CARE
FL00000OtherUNITED HEALTH CARE
GA00239676AMedicaid
FL00000OtherBEECH ST/CAPP CARE
FL00000OtherSOUTHCARE
FL00000OtherUNIVERSAL HEALTH CARE