Provider Demographics
NPI:1720242365
Name:REZNIKOV, BORIS (MD)
Entity type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:REZNIKOV
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 1:5936 LIMESTONE RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:HOCKESSIN
Mailing Address - State:DE
Mailing Address - Zip Code:19707-8930
Mailing Address - Country:US
Mailing Address - Phone:302-234-5800
Mailing Address - Fax:302-234-2380
Practice Address - Street 1:5936 LIMESTONE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:HOCKESSIN
Practice Address - State:DE
Practice Address - Zip Code:19707-8930
Practice Address - Country:US
Practice Address - Phone:302-234-5800
Practice Address - Fax:302-234-2380
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT1937752085N0700X, 390200000X
DEC1-00091202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1720242365Medicaid
DE1720242365OtherRR MEDICARE
DE1720242365OtherRR MEDICARE