Provider Demographics
NPI:1700993581
Name:PRENTICE, MARY ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:PRENTICE
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:PO BOX 2421
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-1400
Mailing Address - Country:US
Mailing Address - Phone:830-214-7012
Mailing Address - Fax:830-331-2475
Practice Address - Street 1:1331 BANDERA HWY STE 2
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-9535
Practice Address - Country:US
Practice Address - Phone:830-258-6237
Practice Address - Fax:830-895-7757
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2778207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140822103Medicaid
TXBP6626937OtherDEA
TX140822103Medicaid
TXTXB152070Medicare PIN
TXBP6626937OtherDEA