Provider Demographics
NPI:1861448078
Name:DREZNICK, ELLIOTT B (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:B
Last Name:DREZNICK
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 1:1174 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3057
Mailing Address - Country:US
Mailing Address - Phone:631-642-9090
Mailing Address - Fax:631-642-2475
Practice Address - Street 1:1174 ROUTE 112
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3057
Practice Address - Country:US
Practice Address - Phone:631-642-9090
Practice Address - Fax:631-642-2475
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164235207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD91939Medicare UPIN