Provider Demographics
NPI:1275596918
Name:RESNICK, JOEL STUART
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:STUART
Last Name:RESNICK
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JOEL
Other - Middle Name:STUART
Other - Last Name:RESNICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:14175 HALF MOON BAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-2906
Mailing Address - Country:US
Mailing Address - Phone:858-205-3851
Mailing Address - Fax:858-509-1960
Practice Address - Street 1:7281 DUMOSA AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-3769
Practice Address - Country:US
Practice Address - Phone:760-365-1882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE-2177213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE-2177OtherLICENSE
CAP00140360OtherRAILROAD PALMETTO PROVIDER
CAE2177OtherMEDICARE PTAN
CAP00140360OtherRAILROAD PALMETTO PROVIDER
CAE2177OtherMEDICARE PTAN