Provider Demographics
NPI:1124008867
Name:MCKENZIE, CHARLES MIDDLETON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MIDDLETON
Last Name:MCKENZIE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 DEVINE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29208-0001
Mailing Address - Country:US
Mailing Address - Phone:803-777-3175
Mailing Address - Fax:
Practice Address - Street 1:1409 DEVINE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29208-0001
Practice Address - Country:US
Practice Address - Phone:803-777-3175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC10824208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCC60461Medicare UPIN