Provider Demographics
NPI:1205871456
Name:DOCTOR, DOLLY PRERAK (MD)
Entity type:Individual
Prefix:DR
First Name:DOLLY
Middle Name:PRERAK
Last Name:DOCTOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5141 DEL MAR MESA RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-6812
Mailing Address - Country:US
Mailing Address - Phone:432-528-2527
Mailing Address - Fax:
Practice Address - Street 1:477 N EL CAMINO REAL STE A208
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1329
Practice Address - Country:US
Practice Address - Phone:432-528-2527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0476207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F40567Medicare UPIN
TX00J42RMedicare ID - Type Unspecified
TX098903001Medicaid