Provider Demographics
NPI:1114919784
Name:RESNECK-SANNES, LARRY DAVID (MD)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:DAVID
Last Name:RESNECK-SANNES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:RESNECK-SANNES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:216 SUBURBIA AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-1252
Mailing Address - Country:US
Mailing Address - Phone:831-905-3683
Mailing Address - Fax:831-438-5229
Practice Address - Street 1:5403 SCOTTS VALLEY DR
Practice Address - Street 2:SUITE A
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-3401
Practice Address - Country:US
Practice Address - Phone:831-438-5222
Practice Address - Fax:831-438-5229
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25952208600000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G259520Medicare ID - Type Unspecified
A42851Medicare UPIN