Basic Information
| Provider Information | |||||||||
| NPI: | 1679828438 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACRANDER | ||||||||
| FirstName: | MARIETTE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 332 S JUNIPER ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920254941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662282236 | ||||||||
| FaxNumber: | 7607373430 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 E 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920254212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662282236 | ||||||||
| FaxNumber: | 7607377324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2012 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | EC121095 | ME | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD171713 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | C167604 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1679828438 | 05 | WA | MEDICAID | R182970 | 01 | OR | MEDICARE | OTHER | 500692170 | 05 | OR | MEDICAID |