Provider Demographics
NPI:1265951172
Name:VASCONCELLOSDE MACEDO, ETIENNE MARIA (MD)
Entity type:Individual
Prefix:
First Name:ETIENNE
Middle Name:MARIA
Last Name:VASCONCELLOSDE MACEDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ETIENNE
Other - Middle Name:MARIA
Other - Last Name:VASCONCELLOS DE MACEDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:FILE 57326
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-7326
Mailing Address - Country:US
Mailing Address - Phone:858-249-6748
Mailing Address - Fax:
Practice Address - Street 1:4168 FRONT ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2030
Practice Address - Country:US
Practice Address - Phone:800-926-8273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA176287207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology