MEDICARE: MARK PRETORIUS, M.D. P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	F4392	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DD4519	OTHER	TX	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0050RP	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1336288315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK PRETORIUS, M.D. P.A.

Provider Business Mailing Address
First Line	:	5201 CORINTHIAN BAY DR
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-4028
Country	:	US
Telephone Number	:	972-596-5144
Fax Number	:	972-596-2128

Provider Business Practice Location Address
First Line	:	5201 CORINTHIAN BAY DR
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-4028
Country	:	US
Telephone Number	:	972-596-5144
Fax Number	:	972-596-2128

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARK PRETORIUS
Credential	:	M.D.
Telephone Number	:	972-596-5144

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	11/05/2015

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