Provider Demographics
NPI:1770589889
Name:SPIVAK, TARAS WALTER (OD)
Entity type:Individual
Prefix:DR
First Name:TARAS
Middle Name:WALTER
Last Name:SPIVAK
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 1:128 N DELSEA DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08312-1602
Mailing Address - Country:US
Mailing Address - Phone:856-881-4089
Mailing Address - Fax:856-881-4013
Practice Address - Street 1:128 N DELSEA DR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NJ
Practice Address - Zip Code:08312-1602
Practice Address - Country:US
Practice Address - Phone:856-881-4089
Practice Address - Fax:856-881-4013
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2010-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00290500152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU21528Medicare UPIN
NJSP521149Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER