Provider Demographics
NPI:1043327570
Name:MCCRACKEN, MARJORIE FROST (MD PHD)
Entity type:Individual
Prefix:DR
First Name:MARJORIE
Middle Name:FROST
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:MISS
Other - First Name:MARJORIE
Other - Middle Name:AUGUSTA
Other - Last Name:FROST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2577 SAMARITAN DR
Mailing Address - Street 2:STE 815
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124
Mailing Address - Country:US
Mailing Address - Phone:408-358-3573
Mailing Address - Fax:408-356-2888
Practice Address - Street 1:2577 SAMARITAN DR
Practice Address - Street 2:STE 815
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124
Practice Address - Country:US
Practice Address - Phone:408-358-3573
Practice Address - Fax:408-356-2888
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG595362080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA770558210OtherFEDERAL TAX ID
CA00G565360Medicaid
CA770558210OtherFEDERAL TAX ID
CA00G565360Medicaid