Provider Demographics
NPI:1972912251
Name:ELLIOTT MASSENBURG, MAKENZIE KATHERINE (OD)
Entity Type:Individual
Prefix:DR
First Name:MAKENZIE
Middle Name:KATHERINE
Last Name:ELLIOTT MASSENBURG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MAKENZIE
Other - Middle Name:KATHERINE
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 MECHANIC STREET
Mailing Address - Street 2:
Mailing Address - City:FOXBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02035
Mailing Address - Country:US
Mailing Address - Phone:508-543-4840
Mailing Address - Fax:508-698-1013
Practice Address - Street 1:25 MECHANIC STREET
Practice Address - Street 2:
Practice Address - City:FOXBORO
Practice Address - State:MA
Practice Address - Zip Code:02035
Practice Address - Country:US
Practice Address - Phone:508-543-4840
Practice Address - Fax:508-698-1013
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5031152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist