Provider Demographics
NPI:1114066313
Name:SPIVACK, JOEL L (DPM)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:L
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 1:978 RTE 45 RM 109
Mailing Address - Street 2:STE 109
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970
Mailing Address - Country:US
Mailing Address - Phone:845-354-2700
Mailing Address - Fax:845-354-2809
Practice Address - Street 1:978 RTE 45 RM 109
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970
Practice Address - Country:US
Practice Address - Phone:845-354-2700
Practice Address - Fax:845-354-2809
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0026261213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T50828Medicare UPIN