Provider Demographics
NPI:1861475691
Name:RESNECK, JACK S (MD)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:S
Last Name:RESNECK
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 1:845 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104
Mailing Address - Country:US
Mailing Address - Phone:318-222-3278
Mailing Address - Fax:318-424-3155
Practice Address - Street 1:845 OLIVE ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104
Practice Address - Country:US
Practice Address - Phone:318-222-3278
Practice Address - Fax:318-424-3155
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01957207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1143839Medicaid
LA1143839Medicaid
B61022Medicare UPIN