Provider Demographics
NPI:1902989502
Name:REZNIKOFF, DMITRY (DO)
Entity type:Individual
Prefix:DR
First Name:DMITRY
Middle Name:
Last Name:REZNIKOFF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6433 99TH ST
Mailing Address - Street 2:MEDICAL OFFICE SUITE
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3522
Mailing Address - Country:US
Mailing Address - Phone:718-275-3587
Mailing Address - Fax:718-275-3587
Practice Address - Street 1:6433 99TH ST
Practice Address - Street 2:MEDICAL OFFICE SUITE
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3522
Practice Address - Country:US
Practice Address - Phone:718-275-3587
Practice Address - Fax:718-275-3587
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231092207R00000X
OH34.009711207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02551522Medicaid
OH0054696Medicaid
WV3810024787Medicaid
NYI03277Medicare UPIN
OH0054696Medicaid
OHH046312Medicare PIN