Basic Information
| Provider Information | |||||||||
| NPI: | 1184088015 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DRESSELHOUSE | ||||||||
| FirstName: | MARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 S LAMAR BLVD APT 2008 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787042944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102870400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18780 INTERSTATE 20 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751033593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035674841 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2016 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | R6554 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 387166707 | 05 | TX | MEDICAID | 387166706 | 05 | TX | MEDICAID |