Provider Demographics
NPI:1659405249
Name:MINCEY, MACKENZIE LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:MACKENZIE
Middle Name:LEE
Last Name:MINCEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MACKENZIE
Other - Middle Name:LEE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1247 SUNCREST TOWN CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1876
Mailing Address - Country:US
Mailing Address - Phone:304-599-8000
Mailing Address - Fax:304-599-8003
Practice Address - Street 1:110 SIMS CIRCLE
Practice Address - Street 2:
Practice Address - City:TRIADELPHIA
Practice Address - State:WV
Practice Address - Zip Code:26059-1154
Practice Address - Country:US
Practice Address - Phone:304-599-8000
Practice Address - Fax:304-599-8003
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26742208000000X
OH35127525208000000X
SC28153208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0170258Medicaid
SC281536Medicaid
WV1659405249Medicaid