Healthcare Provider Details

I. General information

NPI: 1497195176
Provider Name (Legal Business Name): ANTONIN JIRI REZNICEK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14015 SANFORD AVE
FLUSHING NY
11355-2686
US

IV. Provider business mailing address

55 WATER STREET 2ND FLOOR CRED DEPT
NEW YORK NY
10041-0004
US

V. Phone/Fax

Practice location:
  • Phone: 718-826-4000
  • Fax: 718-826-4075
Mailing address:
  • Phone: 646-680-2888
  • Fax: 516-542-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number285603
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number285603
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: