Provider Demographics
NPI:1558659326
Name:MACRAE, MALLORY CHRISTINE (OD)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:CHRISTINE
Last Name:MACRAE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 CHERRY AVE NE
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-4855
Mailing Address - Country:US
Mailing Address - Phone:503-393-6060
Mailing Address - Fax:503-393-5096
Practice Address - Street 1:4350 CHERRY AVE NE
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4855
Practice Address - Country:US
Practice Address - Phone:503-393-6060
Practice Address - Fax:503-393-5096
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR 3408ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500636799Medicaid
ORR160195Medicare PIN