Healthcare Provider Details

I. General information

NPI: 1043327570
Provider Name (Legal Business Name): MARJORIE FROST MCCRACKEN MD PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS MARJORIE AUGUSTA FROST

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2577 SAMARITAN DR STE 815
SAN JOSE CA
95124
US

IV. Provider business mailing address

2577 SAMARITAN DR STE 815
SAN JOSE CA
95124
US

V. Phone/Fax

Practice location:
  • Phone: 408-358-3573
  • Fax: 408-356-2888
Mailing address:
  • Phone: 408-358-3573
  • Fax: 408-356-2888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberG59536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: