Healthcare Provider Details

I. General information

NPI: 1457330151
Provider Name (Legal Business Name): PAUL D REZNIKOV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 04/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E GENESEE ST SUITE 100
SYRACUSE NY
13210-1892
US

IV. Provider business mailing address

1000 E GENESEE ST SUITE 100
SYRACUSE NY
13210-1892
US

V. Phone/Fax

Practice location:
  • Phone: 315-472-8835
  • Fax: 315-476-3712
Mailing address:
  • Phone: 315-269-9729
  • Fax: 315-472-3712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number195195
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number195195
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: