Healthcare Provider Details

I. General information

NPI: 1851475776
Provider Name (Legal Business Name): DMITRIY REZNIK P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NE 3RD AVE STE 1500
FORT LAUDERDALE FL
33301-1181
US

IV. Provider business mailing address

3031 TELEGRAPH AVE
OAKLAND CA
94609-3205
US

V. Phone/Fax

Practice location:
  • Phone: 954-247-8790
  • Fax: 877-594-6196
Mailing address:
  • Phone: 510-596-8125
  • Fax: 510-225-2745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number57357
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.002843
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number019136
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9117176
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: