Provider Demographics
NPI:1003270224
Name:REZNIK, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:REZNIK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11050 71ST RD APT 8E
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4970
Mailing Address - Country:US
Mailing Address - Phone:973-572-9972
Mailing Address - Fax:
Practice Address - Street 1:1641 3RD AVE STE 201
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-3623
Practice Address - Country:US
Practice Address - Phone:973-572-9972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070359-1261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health