Provider Demographics
NPI:1568409753
Name:SPIVACK, ROBERT NEIL (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:NEIL
Last Name:SPIVACK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 ROUTE 42
Mailing Address - Street 2:UNIT 360
Mailing Address - City:TURNERSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08012
Mailing Address - Country:US
Mailing Address - Phone:856-875-8989
Mailing Address - Fax:856-875-6978
Practice Address - Street 1:3501 ROUTE 42
Practice Address - Street 2:UNIT 360
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012-1752
Practice Address - Country:US
Practice Address - Phone:856-875-8989
Practice Address - Fax:856-875-6978
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00462500152W00000X
NJ27TO00054600152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2343304Medicaid
NJ218246Medicare PIN
NJT30124Medicare UPIN