Provider Demographics
NPI:1760574552
Name:MACKENZIE, WILLIAM G (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:G
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:1600 ROCKLAND RD
Practice Address - Street 2:NEMOURS DUPONT PEDIATRICS
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3607
Practice Address - Country:US
Practice Address - Phone:302-651-4000
Practice Address - Fax:302-651-4945
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2017-03-15
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Provider Licenses
StateLicense IDTaxonomies
DEC10004167207X00000X, 207XP3100X
PAMD054069L207XP3100X
FLME130481207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1426596Medicaid
OH166618Medicaid
MN3671585-00Medicaid
NE10025435100Medicaid
NY1523064Medicaid
NJ5625505Medicaid
KY64050743Medicaid
MD1511416Medicaid
000849T34Medicare PIN
F69218Medicare UPIN
OH166618Medicaid