Provider Demographics
NPI:1770654535
Name:REZNIK, VIVIAN MARY (MD)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:MARY
Last Name:REZNIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3860 CALLE FORTUNADA
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4800
Mailing Address - Country:US
Mailing Address - Phone:858-309-6303
Mailing Address - Fax:858-309-6301
Practice Address - Street 1:8001 FROST ST
Practice Address - Street 2:ENTRANCE 10
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2746
Practice Address - Country:US
Practice Address - Phone:858-966-8052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2011-09-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG36058208000000X, 2080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G360580Medicaid