Healthcare Provider Details

I. General information

NPI: 1043244296
Provider Name (Legal Business Name): GARY REZNIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6333 WILSHIRE BLVD #200
LOS ANGELES CA
90048
US

IV. Provider business mailing address

6333 WILSHIRE BLVD #200
LOS ANGELES CA
90048
US

V. Phone/Fax

Practice location:
  • Phone: 323-653-2504
  • Fax: 323-653-2505
Mailing address:
  • Phone: 323-653-2504
  • Fax: 323-653-2515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG67314A
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: