Provider Demographics
NPI:1285659243
Name:MCKENZIE, MARK EDWIN (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWIN
Last Name:MCKENZIE
Suffix:
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 1:2010 GOLDRING AVE
Mailing Address - Street 2:100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4002
Mailing Address - Country:US
Mailing Address - Phone:702-588-7373
Mailing Address - Fax:702-588-7748
Practice Address - Street 1:2010 GOLDRING AVE
Practice Address - Street 2:100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4002
Practice Address - Country:US
Practice Address - Phone:702-588-7373
Practice Address - Fax:702-588-7748
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9051207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2018217Medicaid
NV104320Medicare PIN
NV31986Medicare ID - Type Unspecified
NV2018217Medicaid