Provider Demographics
NPI:1508801283
Name:MACKENZIE, MARY THERESA (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:THERESA
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 CORNERSTEONE DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27519
Mailing Address - Country:US
Mailing Address - Phone:919-460-7676
Mailing Address - Fax:919-460-4605
Practice Address - Street 1:270 CORNERSTEONE DR
Practice Address - Street 2:SUITE 105
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27519
Practice Address - Country:US
Practice Address - Phone:919-460-7676
Practice Address - Fax:919-460-4605
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC9700320207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G60452Medicare UPIN