Provider Demographics
NPI:1982819421
Name:REZNIKOV, TATYANA (MD)
Entity Type:Individual
Prefix:DR
First Name:TATYANA
Middle Name:
Last Name:REZNIKOV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TATYANA
Other - Middle Name:
Other - Last Name:KHAZANOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:116 WESTMINSTER PIKE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-1027
Mailing Address - Country:US
Mailing Address - Phone:410-833-1011
Mailing Address - Fax:
Practice Address - Street 1:116 WESTMINSTER PIKE
Practice Address - Street 2:SUITE 106
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-1027
Practice Address - Country:US
Practice Address - Phone:410-833-1011
Practice Address - Fax:410-833-1705
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00660802081P2900X, 204R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD512314300Medicaid
MD130198OtherMEDICARE PTAN