Provider Demographics
NPI:1720199706
Name:MACKENZIE, CLEVE S (MD)
Entity Type:Individual
Prefix:DR
First Name:CLEVE
Middle Name:S
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:18582 MAIN ST
Mailing Address - Street 2:ATTN: HANA AYOUB
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1701
Mailing Address - Country:US
Mailing Address - Phone:714-965-9696
Mailing Address - Fax:714-965-9797
Practice Address - Street 1:18582 MAIN ST
Practice Address - Street 2:ATTN: HANA AYOUB
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1701
Practice Address - Country:US
Practice Address - Phone:714-965-9696
Practice Address - Fax:714-965-9797
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG68752207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G687520Medicaid
CAF1942Medicare UPIN
CA00G687520Medicaid