1316988140 NPI number — MARK REZNIK DO

Table of content: MARK REZNIK DO (NPI 1316988140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316988140 NPI number — MARK REZNIK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REZNIK
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1316988140
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3801 WAKE FOREST RD STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27609-6864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-787-7246
Provider Business Mailing Address Fax Number:
919-787-7247

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10880 DURANT RD STE 324
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27614-6629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-787-7246
Provider Business Practice Location Address Fax Number:
919-787-7247
Provider Enumeration Date:
06/10/2006

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: 208100000X , with the licence number:  2009-00863 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208VP0000X , with the licence number: 2009-00863 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 152RM . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 59-11943 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2208572 . This is a "MAMSI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 4256796 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7078808 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: P00725886 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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