1205158300 NPI number — DR. MIKALA DAWN REZNIK PT,DPT

Table of content: DR. MIKALA DAWN REZNIK PT,DPT (NPI 1205158300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205158300 NPI number — DR. MIKALA DAWN REZNIK PT,DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REZNIK
Provider First Name:
MIKALA
Provider Middle Name:
DAWN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT,DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RATLIFF
Provider Other First Name:
MIKALA
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205158300
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1508 N GRANDVIEW AVE STE 5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79761-3040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-889-9070
Provider Business Mailing Address Fax Number:
432-552-9949

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1508 N GRANDVIEW AVE STE 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79761-3040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-888-9070
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/17/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1146074 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1146074 . This is a "PT LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".