Provider Demographics
NPI:1457362576
Name:SPIVACK, GARY ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ROBERT
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 1:5404 16TH ST N
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-2763
Mailing Address - Country:US
Mailing Address - Phone:703-532-5520
Mailing Address - Fax:
Practice Address - Street 1:2501 N GLEBE RD
Practice Address - Street 2:SUITE 303
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22207-3558
Practice Address - Country:US
Practice Address - Phone:703-841-1290
Practice Address - Fax:703-841-1315
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0284722084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry