Provider Demographics
NPI:1821182452
Name:MCKENZIE, MICHELLE MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MARIE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 BROWNING GATE ROAD
Mailing Address - Street 2:PO BOX 398
Mailing Address - City:ESTILL
Mailing Address - State:SC
Mailing Address - Zip Code:29918
Mailing Address - Country:US
Mailing Address - Phone:803-625-3384
Mailing Address - Fax:803-625-3579
Practice Address - Street 1:2010 BROWNING GATE ROAD
Practice Address - Street 2:
Practice Address - City:ESTILL
Practice Address - State:SC
Practice Address - Zip Code:29918
Practice Address - Country:US
Practice Address - Phone:803-625-3384
Practice Address - Fax:803-625-3579
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1187152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD11878Medicaid
SCU885227252Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
SCU88522Medicare UPIN