Provider Demographics
NPI:1447233069
Name:SPIVAK, SVETLANA (MD)
Entity Type:Individual
Prefix:DR
First Name:SVETLANA
Middle Name:
Last Name:SPIVAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8631 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-3413
Mailing Address - Country:US
Mailing Address - Phone:718-258-9888
Mailing Address - Fax:347-462-4257
Practice Address - Street 1:2287 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-3029
Practice Address - Country:US
Practice Address - Phone:718-258-9888
Practice Address - Fax:347-462-4257
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210760208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY551441Medicare ID - Type Unspecified
NYG79466Medicare UPIN
NY01878940Medicare ID - Type Unspecified