Provider Demographics
NPI:1497790513
Name:SPIVACK, JONATHAN W (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:W
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 1:850 HARVARD WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-2055
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:75 PRINGLE WAY STE 401
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1476
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-2973
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38942-0202084N0400X
NV124722084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
11006113OtherCAQH
NVP01019331OtherRAILROAD MEDICARE
NV1497790513Medicaid
E92882Medicare UPIN
NVP01019331OtherRAILROAD MEDICARE