Healthcare Provider Details

I. General information

NPI: 1386900595
Provider Name (Legal Business Name): TRAVIS TODD MCKENZIE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 HARRISON BLVD
OGDEN UT
84403
US

IV. Provider business mailing address

5444 S GREEN ST
MURRAY UT
84123-5632
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-2800
  • Fax:
Mailing address:
  • Phone: 801-313-4110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number10246349-1204
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number10246349-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: