Healthcare Provider Details

I. General information

NPI: 1003301557
Provider Name (Legal Business Name): MACKENZIE DICKINSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 07/01/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 PATIENT CARE DR STE A
LANSING MI
48911-4271
US

IV. Provider business mailing address

3955 PATIENT CARE DR STE A
LANSING MI
48911-4271
US

V. Phone/Fax

Practice location:
  • Phone: 517-374-7600
  • Fax: 855-495-5457
Mailing address:
  • Phone: 517-374-7600
  • Fax: 855-495-5457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5101024245
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101025349
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: