Provider Demographics
NPI:1033746649
Name:MACRAE, TYLER MURDOCK (DPM)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:MURDOCK
Last Name:MACRAE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 N HARBOR BLVD STE 35000
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3820
Mailing Address - Country:US
Mailing Address - Phone:714-626-8630
Mailing Address - Fax:
Practice Address - Street 1:2151 N HARBOR BLVD STE 35000
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3820
Practice Address - Country:US
Practice Address - Phone:714-626-8630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC007354213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist