Basic Information
| Provider Information | |||||||||
| NPI: | 1124083456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RESNICK | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3575 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803041825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034490933 | ||||||||
| FaxNumber: | 3034470794 | ||||||||
| Practice Location | |||||||||
| Address1: | 3575 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | BOULDER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 803041825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034490933 | ||||||||
| FaxNumber: | 3034470794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 12/08/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 199481 | NY | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 0058506 | CO | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 37125036 | 05 | CO | MEDICAID | 01576365 | 05 | NY | MEDICAID |