Provider Demographics
NPI:1316982762
Name:JOHN P MCKENZIE III M D INC
Entity type:Organization
Organization Name:JOHN P MCKENZIE III M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:818-502-9420
Mailing Address - Street 1:1510 S CENTRAL AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2500
Mailing Address - Country:US
Mailing Address - Phone:818-247-0346
Mailing Address - Fax:
Practice Address - Street 1:660 W BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1008
Practice Address - Country:US
Practice Address - Phone:818-502-9420
Practice Address - Fax:818-243-9605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG71752207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Single Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G717520Medicaid
CA00G717520Medicaid
G71752Medicare ID - Type Unspecified