Provider Demographics
NPI:1508951427
Name:MACKENZIE, RICHARD GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:GEORGE
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 1:5000 W SUNSET BLVD
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-5861
Mailing Address - Country:US
Mailing Address - Phone:323-361-3824
Mailing Address - Fax:323-953-8116
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:MS# 2
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-669-2112
Practice Address - Fax:323-913-3691
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA243782080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A243780Medicaid
CA00A243780 G10OtherCAL OPTIMA
CAA83006Medicare UPIN
CAWA24378Medicare PIN