Provider Demographics
NPI:1205288784
Name:REZNIKOV, ALISA (MD)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:REZNIKOV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:597 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2590
Mailing Address - Country:US
Mailing Address - Phone:732-294-2540
Mailing Address - Fax:732-409-2621
Practice Address - Street 1:597 PARK AVE
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2590
Practice Address - Country:US
Practice Address - Phone:732-294-2540
Practice Address - Fax:732-409-2621
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10655500207RG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine