Healthcare Provider Details

I. General information

NPI: 1083611958
Provider Name (Legal Business Name): MARK J PTACEK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 CHARLES ST
DEADWOOD SD
57732-1303
US

IV. Provider business mailing address

353 FAIRMONT BLVD ATTN MSS
RAPID CITY SD
57701-7375
US

V. Phone/Fax

Practice location:
  • Phone: 605-717-6431
  • Fax:
Mailing address:
  • Phone: 605-755-8107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16764
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4872
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: