Provider Demographics
NPI:1437356268
Name:MACKENZIE, JOHN DEWOLFE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DEWOLFE
Last Name:MACKENZIE
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 1:19020 33RD AVE W STE 210
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-4748
Mailing Address - Country:US
Mailing Address - Phone:425-563-1500
Mailing Address - Fax:425-563-1374
Practice Address - Street 1:19020 33RD AVE W STE 210
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036
Practice Address - Country:US
Practice Address - Phone:425-563-1500
Practice Address - Fax:425-563-1501
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA995002085P0229X, 2085R0202X
WAMD609427832085R0202X, 2085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0408813OtherL&I-EVERGREEN RADIA
WA0408817OtherL&I-SEATTLE RADIOLOGY
WA0408810OtherL&I-RADIA REST OF WA
WA0408811OtherL&I-RADIA KING COUNTY
WA0408816OtherL&I-SOUTH SOUND RADIOLOGY
WA0408812OtherL&I-SWEDISH RADIA EDMONDS
WA1091767Medicaid