Basic Information
| Provider Information | |||||||||
| NPI: | 1386900595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCKENZIE | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | TODD | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5444 S GREEN ST | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841235632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013134110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4401 HARRISON BLVD | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013872800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2012 | ||||||||
| LastUpdateDate: | 09/26/2018 | ||||||||
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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 | 2085R0204X | 10246349-1204 | UT | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 10246349-1204 | UT | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.