Provider Demographics
NPI:1386900595
Name:MCKENZIE, TRAVIS TODD (DO)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:TODD
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5444 S GREEN ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5632
Mailing Address - Country:US
Mailing Address - Phone:801-313-4110
Mailing Address - Fax:
Practice Address - Street 1:4401 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403
Practice Address - Country:US
Practice Address - Phone:801-387-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10246349-12042085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology