Provider Demographics
NPI:1083611958
Name:PTACEK, MARK J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:PTACEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:353 FAIRMONT BLVD
Mailing Address - Street 2:ATTN MSS
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7375
Mailing Address - Country:US
Mailing Address - Phone:605-755-8107
Mailing Address - Fax:
Practice Address - Street 1:71 CHARLES ST
Practice Address - Street 2:
Practice Address - City:DEADWOOD
Practice Address - State:SD
Practice Address - Zip Code:57732-1303
Practice Address - Country:US
Practice Address - Phone:605-717-6431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16764207Q00000X
SD4872207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE460423930OtherHUMANA
NE46042393011Medicaid
NE9214155OtherDAKOTA CARE
NE3859OtherMIDLANDS CHOICE
NE7988021OtherAETNA
NE0123937OtherMEDICA
NE06676OtherNEBRASKA BCBS
NE460423930OtherTRICARE
NE0747440002Medicare NSC
NE0123937OtherMEDICA
NE460423930OtherHUMANA
NE9214155OtherDAKOTA CARE