Provider Demographics
NPI:1902839418
Name:PRETORIUS, DOLORES H (MD)
Entity Type:Individual
Prefix:DR
First Name:DOLORES
Middle Name:H
Last Name:PRETORIUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:9300 CAMPUS POINT DR
Mailing Address - Street 2:MAIL CODE 7756
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1300
Mailing Address - Country:US
Mailing Address - Phone:858-657-6698
Mailing Address - Fax:858-657-6697
Practice Address - Street 1:9300 CAMPUS POINT DR
Practice Address - Street 2:MAIL CODE 7756
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1300
Practice Address - Country:US
Practice Address - Phone:858-657-6698
Practice Address - Fax:858-657-6697
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC391022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C391020Medicaid
CAA37059Medicare UPIN
CA00C391020Medicaid
CAWC39102AMedicare ID - Type Unspecified