Provider Demographics
NPI:1295750305
Name:SPIVACK, BRIAN (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
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 1:8263 GROVE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3107
Mailing Address - Country:US
Mailing Address - Phone:909-946-5320
Mailing Address - Fax:909-946-3290
Practice Address - Street 1:8263 GROVE AVE STE 204
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3107
Practice Address - Country:US
Practice Address - Phone:909-946-5320
Practice Address - Fax:909-946-3290
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG673602086X0206X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF57691Medicare UPIN
00G673600Medicare ID - Type Unspecified