Healthcare Provider Details

I. General information

NPI: 1699780197
Provider Name (Legal Business Name): OLEG I REZNIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MAIN ST BLDG 11
BAR HARBOR ME
04609-1523
US

IV. Provider business mailing address

43 WHITING HILL RD STE 300
BREWER ME
04412-1006
US

V. Phone/Fax

Practice location:
  • Phone: 207-288-1600
  • Fax: 207-288-1601
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD19741
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: