Provider Demographics
NPI:1336296789
Name:SPIVACK, ERIC M (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:M
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 1:21110 BISCAYNE BLVD
Mailing Address - Street 2:STE 208
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180
Mailing Address - Country:US
Mailing Address - Phone:305-692-9299
Mailing Address - Fax:888-243-6962
Practice Address - Street 1:21110 BISCAYNE BLVD
Practice Address - Street 2:STE 208
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1251
Practice Address - Country:US
Practice Address - Phone:305-692-9299
Practice Address - Fax:305-692-8668
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 50897207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL047753200Medicaid
FL047753200Medicaid
FL03942XMedicare Oscar/Certification