Provider Demographics
NPI:1568475465
Name:RESNICK, JACK S (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:S
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 1:300 FIR ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2327
Mailing Address - Country:US
Mailing Address - Phone:619-446-1586
Mailing Address - Fax:
Practice Address - Street 1:300 FIR ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2327
Practice Address - Country:US
Practice Address - Phone:619-446-1586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC318182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C318180Medicaid
CAWC31818AMedicare ID - Type Unspecified
CAA34718Medicare UPIN