Provider Demographics
NPI:1689931206
Name:MCKENZIE, NICHOLAS A (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:A
Last Name:MCKENZIE
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 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:
Practice Address - Street 1:3535 PENTAGON BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-1705
Practice Address - Country:US
Practice Address - Phone:937-702-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
OH35.123040208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No171000000XOther Service ProvidersMilitary Health Care Provider