Provider Demographics
NPI:1962689380
Name:NELSON, MACKENZI J (DPM)
Entity Type:Individual
Prefix:DR
First Name:MACKENZI
Middle Name:J
Last Name:NELSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 HUEHL RD
Mailing Address - Street 2:#13
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2319
Mailing Address - Country:US
Mailing Address - Phone:847-504-5000
Mailing Address - Fax:847-504-5015
Practice Address - Street 1:425 HUEHL RD
Practice Address - Street 2:#13
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2319
Practice Address - Country:US
Practice Address - Phone:847-504-5000
Practice Address - Fax:847-504-5015
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLL9464213ES0103X
IN99040479A213E00000X
IN07001100A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP01242897OtherRAILROAD MEDICARE
AR199966717Medicaid
AR311652YKAUMedicare PIN
INP00832687Medicare PIN
IN859800EEMedicare PIN