Healthcare Provider Details

I. General information

NPI: 1942569231
Provider Name (Legal Business Name): MACKENZIE LEE GOODWIN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MACKENZIE LEE BEAR M.D

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 07/18/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MACKENZIE GOODWIN MD DBA WASATCH SURGICAL LLC 520 MEDICAL DR STE 300
BOUNTIFUL UT
84010
US

IV. Provider business mailing address

1893 E MILLBROOK RD
SALT LAKE CITY UT
84106-3827
US

V. Phone/Fax

Practice location:
  • Phone: 228-273-9021
  • Fax:
Mailing address:
  • Phone: 228-273-9021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number11768709-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number11768709-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number11768709-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: