Provider Demographics
NPI:1780211938
Name:GOODRICH, MACKENZIE (DO)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:GOODRICH
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 1:11555 E SPEEDWAY BLVD UNIT 8
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85748-2079
Mailing Address - Country:US
Mailing Address - Phone:860-690-2486
Mailing Address - Fax:
Practice Address - Street 1:1906 BELLEVIEW AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1838
Practice Address - Country:US
Practice Address - Phone:540-981-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program