Healthcare Provider Details

I. General information

NPI: 1114925500
Provider Name (Legal Business Name): CHAD M MCKENZIE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 01/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5818 HARBOUR VIEW BLVD STE 240
SUFFOLK VA
23435
US

IV. Provider business mailing address

5818 HARBOUR VIEW BLVD STE 240
SUFFOLK VA
23435
US

V. Phone/Fax

Practice location:
  • Phone: 757-397-2383
  • Fax: 757-397-5201
Mailing address:
  • Phone: 757-397-2383
  • Fax: 757-397-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number0102201282
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: