Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | G36058 | CA |
Y | 2080P0210X | Pediatric Nephrologist | G36058 | CA |
NPI | 1770654535 |
---|---|
Provider Name | Vivian Mary Reznik |
First Address | San Diego, CA 92123-4800 |
Second Address | San Diego, CA 92123-2746 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/11/2006 |
Last Update Date | 07/09/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G360580 | (05) | CA |