Provider Demographics
NPI:1609868884
Name:SPIVAK, JEFFREY ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:SPIVAK
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 1:488 GREAT NECK RD
Mailing Address - Street 2:SUITE 330
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4308
Mailing Address - Country:US
Mailing Address - Phone:516-482-6747
Mailing Address - Fax:516-482-4851
Practice Address - Street 1:488 GREAT NECK RD
Practice Address - Street 2:SUITE 330
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4308
Practice Address - Country:US
Practice Address - Phone:516-482-6747
Practice Address - Fax:516-482-4851
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191459207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
22N921Medicare ID - Type Unspecified
G04398Medicare UPIN