Provider Demographics
NPI:1679828438
Name:MACRANDER, MARIETTE A (MD)
Entity Type:Individual
Prefix:
First Name:MARIETTE
Middle Name:A
Last Name:MACRANDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 S JUNIPER ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4941
Mailing Address - Country:US
Mailing Address - Phone:866-228-2236
Mailing Address - Fax:760-737-3430
Practice Address - Street 1:225 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4212
Practice Address - Country:US
Practice Address - Phone:866-228-2236
Practice Address - Fax:760-737-7324
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEEC121095207Q00000X
ORMD171713207Q00000X
CAC167604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1679828438Medicaid
ORR182970OtherMEDICARE
OR500692170Medicaid