Provider Demographics
NPI:1801380241
Name:DR LAURENCE W SPIVACK DPM INC
Entity Type:Organization
Organization Name:DR LAURENCE W SPIVACK DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:SPIVACK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:440-487-3947
Mailing Address - Street 1:9330 HIDDEN GLEN DR
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-7362
Mailing Address - Country:US
Mailing Address - Phone:440-487-3947
Mailing Address - Fax:513-858-7827
Practice Address - Street 1:9330 HIDDEN GLEN DR
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060
Practice Address - Country:US
Practice Address - Phone:440-487-3947
Practice Address - Fax:513-858-7827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-19
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36001535213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty