Provider Demographics
NPI:1184088015
Name:DRESSELHOUSE, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DRESSELHOUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S LAMAR BLVD APT 2008
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2944
Mailing Address - Country:US
Mailing Address - Phone:810-287-0400
Mailing Address - Fax:
Practice Address - Street 1:18780 INTERSTATE 20
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103-3593
Practice Address - Country:US
Practice Address - Phone:903-567-4841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXR6554207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX387166707Medicaid
TX387166706Medicaid