Provider Demographics
NPI:1740030196
Name:MCKENZIE, OMAR JESSE (MD)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:JESSE
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7702 N ALPINE RD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-3107
Mailing Address - Country:US
Mailing Address - Phone:815-971-3397
Mailing Address - Fax:
Practice Address - Street 1:7702 N ALPINE RD
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-3107
Practice Address - Country:US
Practice Address - Phone:815-971-3397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program