Provider Demographics
NPI:1801846704
Name:REZNICEK, STEPHEN BERNARD (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:BERNARD
Last Name:REZNICEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1787
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520
Mailing Address - Country:US
Mailing Address - Phone:231-779-2565
Mailing Address - Fax:231-775-0744
Practice Address - Street 1:1006 NORTH H STREET
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520
Practice Address - Country:US
Practice Address - Phone:360-537-6470
Practice Address - Fax:360-537-6475
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMC-0557208800000X
MI062640208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI297815510Medicaid
MI0830015Medicare ID - Type Unspecified
MI297815510Medicaid