Healthcare Provider Details

I. General information

NPI: 1336639160
Provider Name (Legal Business Name): MACKENZIE BAKKER GRASSO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 07/06/2024
Certification Date: 07/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15155 SW 97TH AVE STE 200
MIAMI FL
33176-0049
US

IV. Provider business mailing address

1250 E MARSHALL ST
RICHMOND VA
23298-5051
US

V. Phone/Fax

Practice location:
  • Phone: 804-922-2629
  • Fax:
Mailing address:
  • Phone: 804-827-1204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number168646
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: