Provider Demographics
NPI:1285839670
Name:SMITH, MACKENZIE MARIE
Entity Type:Individual
Prefix:DR
First Name:MACKENZIE
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 W ARLINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5704
Mailing Address - Country:US
Mailing Address - Phone:252-413-6202
Mailing Address - Fax:
Practice Address - Street 1:1850 W ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5704
Practice Address - Country:US
Practice Address - Phone:252-413-6202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC2010-01082207Q00000X
NC2010-01082207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916698Medicaid
NC161CPOtherBCBSNC
NC161CPOtherBCBSNC