Basic Information
| Provider Information | |||||||||
| NPI: | 1114189933 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKENZIE | ||||||||
| FirstName: | SHAUN | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722342987 | ||||||||
| Practice Location | |||||||||
| Address1: | 4101 JAMES CASEY ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787451145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124214250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2008 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | 43479 | KY | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 2086X0206X | P6220 | TX | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 330383602 | 05 | TX | MEDICAID | 330383603 | 05 | TX | MEDICAID | 330383604 | 05 | TX | MEDICAID | 330383605 | 05 | TX | MEDICAID | P01867717 | 01 | TX | RAILROAD | OTHER |