Healthcare Provider Details

I. General information

NPI: 1669596136
Provider Name (Legal Business Name): SAMUEL DAVID RESNIK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 HAANAFA STREET
TEL MOND ISRAEL
40600
IL

IV. Provider business mailing address

3 HAANAFA STREET
TEL MOND ISRAEL
40600
IL

V. Phone/Fax

Practice location:
  • Phone: 97297967536
  • Fax: 97297967536
Mailing address:
  • Phone: 97297967536
  • Fax: 97297967536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301037978
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: