1063416683 NPI number — LONNIE RESNICK DPM

Table of content: LONNIE RESNICK DPM (NPI 1063416683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063416683 NPI number — LONNIE RESNICK DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RESNICK
Provider First Name:
LONNIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063416683
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/16/2006
NPI Reactivation Date:
03/24/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
148 EAST AVE STE 1D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORWALK
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06851-5727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-853-6570
Provider Business Mailing Address Fax Number:
203-939-9779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
148 EAST AVE STE 1D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORWALK
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06851-5727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-853-6570
Provider Business Practice Location Address Fax Number:
203-853-2078
Provider Enumeration Date:
06/10/2005

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: 213E00000X , with the licence number:  CT000515 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 030000515CT04 . This is a "ANTHEM BC-BS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004095205 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: OV0227 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: ZS274 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".