MEDICARE: JACOB REZNIK MD, INC., A PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	A101891	CA

General Provider Information

NPI Number	:	1043495724
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACOB REZNIK MD, INC., A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	8568 BURTON WAY
Second Line	:	#102
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-3353
Country	:	US
Telephone Number	:	310-980-6037
Fax Number	:

Provider Business Practice Location Address
First Line	:	16055 VENTURA BLVD
Second Line	:	#690
City	:	ENCINO
State	:	CA
Zip	:	91436-2601
Country	:	US
Telephone Number	:	818-789-5558
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JACOB REZNIK
Credential	:	MD
Telephone Number	:	310-980-6037

Provider Enumeration Date	:	12/31/2007
Last Update Date	:	12/05/2008

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