Provider Demographics
NPI:1982907465
Name:LISA RENEE REZNICK MD, PA
Entity type:Organization
Organization Name:LISA RENEE REZNICK MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:REZNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-395-9000
Mailing Address - Street 1:4100 FAIRWAY CT
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010
Mailing Address - Country:US
Mailing Address - Phone:972-395-9000
Mailing Address - Fax:972-395-9002
Practice Address - Street 1:4100 FAIRWAY DR
Practice Address - Street 2:SUITE 120
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-6525
Practice Address - Country:US
Practice Address - Phone:972-395-9000
Practice Address - Fax:972-395-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0169332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00840QMedicare UPIN