Provider Demographics
NPI:1316931264
Name:MACKENZIE, DIANE (DO)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:MACKENZIE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 WEST GILBERT STREET
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4918
Mailing Address - Country:US
Mailing Address - Phone:732-212-0060
Mailing Address - Fax:732-212-0061
Practice Address - Street 1:495 N 13TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1317
Practice Address - Country:US
Practice Address - Phone:973-268-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07665200207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0023361Medicaid
NJI03685Medicare UPIN
P00389823Medicare PIN
NJ077725Medicare ID - Type Unspecified