Provider Demographics
NPI:1750382651
Name:REZEK, DONALD L (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:L
Last Name:REZEK
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 1:505 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3057
Mailing Address - Country:US
Mailing Address - Phone:814-337-5775
Mailing Address - Fax:814-337-2841
Practice Address - Street 1:505 POPLAR ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3057
Practice Address - Country:US
Practice Address - Phone:814-337-5775
Practice Address - Fax:814-337-2841
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2010-08-09
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
PAMD036712E2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA134259Medicaid
PA428690OtherBLUE SHIELD
PA0011067750003Medicaid
PA205035OtherUPMC FOR YOU
PA130011749Medicare ID - Type UnspecifiedMETRAHEALTH
PA428690Medicare ID - Type Unspecified
PA0011067750003Medicaid