Provider Demographics
NPI:1043215817
Name:SPIVACK, LAURENCE W (DPM)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:W
Last Name:SPIVACK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9330 HIDDEN GLEN DR
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-7362
Mailing Address - Country:US
Mailing Address - Phone:440-487-3947
Mailing Address - Fax:513-858-7827
Practice Address - Street 1:9330 HIDDEN GLEN DR
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060
Practice Address - Country:US
Practice Address - Phone:440-487-3947
Practice Address - Fax:513-858-7827
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36001535213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000242733OtherANTHEM
OH016307OtherUNITED HEALTHCARE
OH0161999Medicaid
OH5673160001Medicare NSC
OH016307OtherUNITED HEALTHCARE
OH0161999Medicaid