Basic Information
| Provider Information | |||||||||
| NPI: | 1487684825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RESNICK | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 848997 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022848997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705697656 | ||||||||
| FaxNumber: | 9705697657 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 BEARD CREEK RD | ||||||||
| Address2: | |||||||||
| City: | EDWARDS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705697656 | ||||||||
| FaxNumber: | 9705697657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 07/27/2009 | ||||||||
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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 | 2086S0122X | G60190 | CA | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 240007817 | 01 | CA | MEDICARE RAILROAD PIN | OTHER | 00G601900 | 01 | CA | BLUE SHIELD PIN | OTHER | 00G601900 | 05 | CA | MEDICAID |