Provider Demographics
NPI:1295705838
Name:WILFRED C MCKENZIE PA
Entity type:Organization
Organization Name:WILFRED C MCKENZIE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILFRED
Authorized Official - Middle Name:CLIFTON
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-832-0055
Mailing Address - Street 1:1625 SE 3RD AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2521
Mailing Address - Country:US
Mailing Address - Phone:954-832-0055
Mailing Address - Fax:954-832-0063
Practice Address - Street 1:1625 SE 3RD AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2521
Practice Address - Country:US
Practice Address - Phone:954-832-0055
Practice Address - Fax:954-832-0063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0059669207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL257017300Medicaid
FL371522100Medicaid
FL257017300Medicaid
FL371522100Medicaid
FLK1038Medicare ID - Type Unspecified