Provider Demographics
NPI:1750778320
Name:HOFFORD, MACKENZIE ROSS (MD)
Entity type:Individual
Prefix:DR
First Name:MACKENZIE
Middle Name:ROSS
Last Name:HOFFORD
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-362-5060
Mailing Address - Fax:314-996-3230
Practice Address - Street 1:4901 FOREST PARK AVE
Practice Address - Street 2:DIV IM GENERAL MED, STE 241
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1495
Practice Address - Country:US
Practice Address - Phone:314-362-5060
Practice Address - Fax:314-996-3230
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020013462207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200084460Medicaid