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NPI Code Detail

MEDICARE: DR. MACKENZIE WILSON ELIAS DO

MEDICARE: DR. MACKENZIE WILSON ELIAS DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1639938145
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MACKENZIE WILSON ELIAS DO
Provider Business Mailing Address
First Line : 6000 49TH ST N
Second Line :
City : ST PETERSBURG
State : FL
Zip : 33709-2114
Country : US
Telephone Number : 727-521-5093
Fax Number :
Provider Business Practice Location Address
First Line : 6000 49TH ST N
Second Line :
City : ST PETERSBURG
State : FL
Zip : 33709-2145
Country : US
Telephone Number : 727-521-5093
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/18/2024
Last Update Date : 03/18/2024

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