Healthcare Provider Details

I. General information

NPI: 1245288687
Provider Name (Legal Business Name): DAVID C MCKENZIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 E AZTEC STE 6
GALLUP NM
87301
US

IV. Provider business mailing address

1808 E AZTEC STE 6
GALLUP NM
87301
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-9374
  • Fax: 505-722-7400
Mailing address:
  • Phone: 505-863-9374
  • Fax: 505-722-7400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number80207
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: