Provider Demographics
NPI:1760449292
Name:RESNECK, JACK S JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:S
Last Name:RESNECK
Suffix:JR
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 1:1635 DIVISADERO ST
Mailing Address - Street 2:STE 625, BOX 1821
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-1821
Mailing Address - Country:US
Mailing Address - Phone:415-476-4029
Mailing Address - Fax:415-476-4150
Practice Address - Street 1:1701 DIVISADERO ST
Practice Address - Street 2:4TH FLOOR DERMATOLOGY FACULTY PRACTICE
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-0316
Practice Address - Country:US
Practice Address - Phone:415-353-7800
Practice Address - Fax:415-353-9654
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66722207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A667220MedicaidPIN
CA00A667220Medicare ID - Type UnspecifiedPIN
CA00A667220MedicaidPIN