Provider Demographics
NPI:1235548975
Name:BLACK, MACKENZIE SHEERIN (OD)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:SHEERIN
Last Name:BLACK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10750 W MCDOWELL RD
Mailing Address - Street 2:A100
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-5960
Mailing Address - Country:US
Mailing Address - Phone:623-877-3007
Mailing Address - Fax:623-877-4488
Practice Address - Street 1:10750 W MCDOWELL RD
Practice Address - Street 2:A100
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-5960
Practice Address - Country:US
Practice Address - Phone:623-877-3007
Practice Address - Fax:623-877-4488
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2005152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist