Provider Demographics
NPI:1457330151
Name:REZNIKOV, PAUL D (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:REZNIKOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E GENESEE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1892
Mailing Address - Country:US
Mailing Address - Phone:315-269-9729
Mailing Address - Fax:315-472-3712
Practice Address - Street 1:1000 E GENESEE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1892
Practice Address - Country:US
Practice Address - Phone:315-472-8835
Practice Address - Fax:315-476-3712
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195195174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00195195Medicaid
NY01490124Medicaid
NY00195195Medicaid
300049820Medicare PIN
NYF55515Medicare UPIN
NY52931GMedicare PIN