Provider Demographics
NPI:1861498297
Name:MACKENZIE, KEITH ANDREW (DO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ANDREW
Last Name:MACKENZIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 11208
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-1208
Mailing Address - Country:US
Mailing Address - Phone:928-541-1312
Mailing Address - Fax:928-541-0002
Practice Address - Street 1:3190 CLEARWATER DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7131
Practice Address - Country:US
Practice Address - Phone:928-541-1312
Practice Address - Fax:928-541-0002
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3225207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ390766Medicaid
AZ390766Medicaid
G53808Medicare UPIN