Provider Demographics
NPI:1285642934
Name:SPIVAK, DANA (MD)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:
Last Name:SPIVAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DANA
Other - Middle Name:
Other - Last Name:SPIVAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:137 PARK AVE
Mailing Address - Street 2:1
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030
Mailing Address - Country:US
Mailing Address - Phone:917-692-9309
Mailing Address - Fax:
Practice Address - Street 1:121 DEKALB AVE
Practice Address - Street 2:FAMILY PRACTICE
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5425
Practice Address - Country:US
Practice Address - Phone:718-250-8444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233463207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2631996Medicaid
NY2631996Medicaid
NY5457A1Medicare ID - Type Unspecified