Provider Demographics
NPI:1346233673
Name:VAN HOOK SPIVACK, LUCILLE REGINA (MD)
Entity Type:Individual
Prefix:DR
First Name:LUCILLE
Middle Name:REGINA
Last Name:VAN HOOK SPIVACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:LUCILLE
Other - Middle Name:REGINA
Other - Last Name:VAN HOOK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:BAY CHESTER POST OFFICE
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-0701
Mailing Address - Country:US
Mailing Address - Phone:718-828-4227
Mailing Address - Fax:718-828-4227
Practice Address - Street 1:1120 MORRIS PARK AVE
Practice Address - Street 2:SUITE 4A
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1400
Practice Address - Country:US
Practice Address - Phone:718-828-4227
Practice Address - Fax:718-828-4227
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY141418207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01095129Medicaid
78F371Medicare ID - Type Unspecified
E87550Medicare UPIN