Provider Demographics
NPI:1194352559
Name:HEYWOOD, MACKENZIE A
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:A
Last Name:HEYWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3132 OLD JACKSONVILLE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7401
Mailing Address - Country:US
Mailing Address - Phone:217-862-0800
Mailing Address - Fax:217-862-0871
Practice Address - Street 1:3132 OLD JACKSONVILLE RD STE 200
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-7401
Practice Address - Country:US
Practice Address - Phone:217-862-0800
Practice Address - Fax:217-862-0871
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0097004208D00000X, 208D00000X
IL036.167992208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036167992OtherMD