Healthcare Provider Details

I. General information

NPI: 1275790958
Provider Name (Legal Business Name): BONNIE SUZANNE MACKENZIE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 MONTAUK AVE
NEW LONDON CT
06320-4700
US

IV. Provider business mailing address

365 MONTAUK AVE
NEW LONDON CT
06320-4700
US

V. Phone/Fax

Practice location:
  • Phone: 860-442-0711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number247472
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License NumberMD13276
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD13276
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number52132
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: