Provider Demographics
NPI:1912900580
Name:PRETORIUS, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:PRETORIUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 CORINTHIAN BAY DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-4028
Mailing Address - Country:US
Mailing Address - Phone:972-596-5144
Mailing Address - Fax:972-596-2128
Practice Address - Street 1:5201 CORINTHIAN BAY DR
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4028
Practice Address - Country:US
Practice Address - Phone:972-596-5144
Practice Address - Fax:972-596-2128
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF43922084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122894205Medicaid
TXP00228944OtherRAILROAD MEDICARE
TX8BL750OtherBCBS
TX8BL750OtherBCBS
B25642Medicare UPIN