Provider Demographics
NPI:1326116948
Name:SPIVACK, BARNEY (MD)
Entity Type:Individual
Prefix:DR
First Name:BARNEY
Middle Name:
Last Name:SPIVACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LONG LOTS RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-3919
Mailing Address - Country:US
Mailing Address - Phone:203-966-2571
Mailing Address - Fax:203-966-2571
Practice Address - Street 1:101 LONG LOTS RD
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880-3919
Practice Address - Country:US
Practice Address - Phone:203-966-2571
Practice Address - Fax:203-966-2571
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030009207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB17411Medicare UPIN