Healthcare Provider Details

I. General information

NPI: 1730673237
Provider Name (Legal Business Name): RAISA VLADIMIR REZNIK MD,DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 COVENTRY WAY
CLINTON MD
20735-2256
US

IV. Provider business mailing address

3000 BIRCHTREE LN
SILVER SPRING MD
20906-3034
US

V. Phone/Fax

Practice location:
  • Phone: 301-868-0157
  • Fax:
Mailing address:
  • Phone: 301-233-5654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14292
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: