Healthcare Provider Details

I. General information

NPI: 1548218993
Provider Name (Legal Business Name): ERNEST J MCKENZIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N. 30TH ST
CLINTON OK
73601-3831
US

IV. Provider business mailing address

PO BOX 96846
OKLAHOMA CITY OK
73143-5818
US

V. Phone/Fax

Practice location:
  • Phone: 405-632-2323
  • Fax: 405-631-9315
Mailing address:
  • Phone: 405-632-2323
  • Fax: 405-631-9315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD486293
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberFM5050656
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number19406
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: