Provider Demographics
NPI:1750020400
Name:BERRY, MACKENZIE REBECCA (DO)
Entity Type:Individual
Prefix:DR
First Name:MACKENZIE
Middle Name:REBECCA
Last Name:BERRY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10906 AIRMEN DR
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-1400
Mailing Address - Country:US
Mailing Address - Phone:303-803-3632
Mailing Address - Fax:
Practice Address - Street 1:7050 AIR DEPOT BLVD STE 1094
Practice Address - Street 2:
Practice Address - City:TINKER AFB
Practice Address - State:OK
Practice Address - Zip Code:73145-8716
Practice Address - Country:US
Practice Address - Phone:405-734-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102208016208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice