Provider Demographics
NPI:1538160064
Name:REZNICOW, NORMAN PAUL (OD)
Entity type:Individual
Prefix:
First Name:NORMAN
Middle Name:PAUL
Last Name:REZNICOW
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7362 UNIVERSITY AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-3151
Mailing Address - Country:US
Mailing Address - Phone:763-571-1800
Mailing Address - Fax:763-571-1880
Practice Address - Street 1:7362 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3151
Practice Address - Country:US
Practice Address - Phone:763-571-1800
Practice Address - Fax:763-571-1880
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1582152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN021823500Medicaid
MN14490REOtherBLUE CROSS
MN580610751Medicare ID - Type Unspecified