Healthcare Provider Details

I. General information

NPI: 1861735292
Provider Name (Legal Business Name): MICAH S. RESNICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2401
US

IV. Provider business mailing address

2520 30TH AVE FL 4
ASTORIA NY
11102-2448
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-4321
  • Fax:
Mailing address:
  • Phone: 718-808-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number282913
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.140363
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: