Provider Demographics
NPI:1255597795
Name:DAILEY, MACKENZIE (MD)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:DAILEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MILITARY TRAIL
Mailing Address - Street 2:SUITE # 300
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458
Mailing Address - Country:US
Mailing Address - Phone:561-741-0000
Mailing Address - Fax:561-745-4212
Practice Address - Street 1:5458 TOWN CENTER ROAD
Practice Address - Street 2:SUITE #101
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486
Practice Address - Country:US
Practice Address - Phone:561-393-8555
Practice Address - Fax:561-393-1904
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105166208000000X
IL125051993208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001267700Medicaid