Provider Demographics
NPI:1417953290
Name:PROCHASKA, MARK LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LAWRENCE
Last Name:PROCHASKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7011 W 121ST ST
Mailing Address - Street 2:STE 105
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66209-2029
Mailing Address - Country:US
Mailing Address - Phone:913-345-1191
Mailing Address - Fax:913-345-1464
Practice Address - Street 1:7011 W 121ST ST
Practice Address - Street 2:STE 105
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-2029
Practice Address - Country:US
Practice Address - Phone:913-345-1191
Practice Address - Fax:913-345-1464
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-211872084P0800X, 2084P0805X, 2084P0802X, 2084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Not Answered2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Not Answered2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0007208CMedicare ID - Type Unspecified
C51594Medicare UPIN