Provider Demographics
NPI:1487684825
Name:RESNICK, JEFFREY I (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:I
Last Name:RESNICK
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:PO BOX 848997
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8997
Mailing Address - Country:US
Mailing Address - Phone:970-569-7656
Mailing Address - Fax:970-569-7657
Practice Address - Street 1:320 BEARD CREEK RD
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632
Practice Address - Country:US
Practice Address - Phone:970-569-7656
Practice Address - Fax:970-569-7657
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG601902086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA240007817OtherMEDICARE RAILROAD PIN
CA00G601900OtherBLUE SHIELD PIN
CA00G601900Medicaid
CA240007817OtherMEDICARE RAILROAD PIN
CAG60190Medicare PIN
CA00G601900OtherBLUE SHIELD PIN