Provider Demographics
NPI:1336174556
Name:PETERSON, MACKENZIE (MD)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:PETERSON
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:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:GARNETT
Mailing Address - State:KS
Mailing Address - Zip Code:66032-0309
Mailing Address - Country:US
Mailing Address - Phone:785-448-2674
Mailing Address - Fax:785-448-3091
Practice Address - Street 1:536 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:GARNETT
Practice Address - State:KS
Practice Address - Zip Code:66032-1355
Practice Address - Country:US
Practice Address - Phone:785-448-2674
Practice Address - Fax:785-448-3091
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-31228207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
7240801OtherAETNA
KS104817OtherBLUE CROSS
KS104817OtherBLUE CROSS
104864Medicare ID - Type Unspecified