Provider Demographics
NPI:1255435632
Name:MCKENZIE, THOMAS EDWARD (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:EDWARD
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 RIA MIRADA CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-3102
Mailing Address - Country:US
Mailing Address - Phone:904-471-5895
Mailing Address - Fax:
Practice Address - Street 1:VA CLINIC 1955 US RT 1 SOUTH
Practice Address - Street 2:STE 200
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086
Practice Address - Country:US
Practice Address - Phone:904-829-0814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216854207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLVAD000Medicare UPIN