Provider Demographics
NPI:1538175203
Name:PFAUTSCH, MARK L (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:PFAUTSCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:70 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4928
Mailing Address - Country:US
Mailing Address - Phone:573-334-6071
Mailing Address - Fax:573-334-4739
Practice Address - Street 1:70 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4928
Practice Address - Country:US
Practice Address - Phone:573-334-6071
Practice Address - Fax:573-334-4739
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8A132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
187175OtherHEALTHLINK
063896OtherHEALTH ALLIANCE
MO242662005Medicaid
MO185214Other185214
AR143794001Medicaid
430954380CAPOtherMERCY HEALTH PLAN
IL036-077507OtherIL BLUE CROSS BLUE SHIELD
187175OtherHEALTHLINK
MO300112050Medicare ID - Type UnspecifiedMO RAILROAD MEDICARE
AR143794001Medicaid
MO185214Other185214
063896OtherHEALTH ALLIANCE