Provider Demographics
NPI:1366705626
Name:PRELACK, MARISA SARA (MD)
Entity type:Individual
Prefix:DR
First Name:MARISA
Middle Name:SARA
Last Name:PRELACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARISA
Other - Middle Name:SARA
Other - Last Name:MANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3401 CIVIC CENTER BLVD
Mailing Address - Street 2:DIVISION OF NEUROLOGY
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4319
Mailing Address - Country:US
Mailing Address - Phone:267-254-9919
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:DIVISION OF NEUROLOGY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:267-254-9919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT201266208000000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics