Provider Demographics
NPI:1578595161
Name:LAWRENCE H RESNICK MD A PROF CORP
Entity Type:Organization
Organization Name:LAWRENCE H RESNICK MD A PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:H
Authorized Official - Last Name:RESNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-528-3466
Mailing Address - Street 1:15335 MORRISON ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1513
Mailing Address - Country:US
Mailing Address - Phone:818-528-3466
Mailing Address - Fax:818-528-3464
Practice Address - Street 1:15335 MORRISON ST
Practice Address - Street 2:SUITE 304
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1513
Practice Address - Country:US
Practice Address - Phone:818-528-3466
Practice Address - Fax:818-528-3464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083060Medicaid
CAZZZ64205ZOtherBLUE SHIELD
CAW18019Medicare PIN