Provider Demographics
NPI:1780617217
Name:SPIVAK, Y LENNY (MD)
Entity type:Individual
Prefix:DR
First Name:Y
Middle Name:LENNY
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:PO BOX 28915
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-8915
Mailing Address - Country:US
Mailing Address - Phone:559-253-2800
Mailing Address - Fax:559-596-2085
Practice Address - Street 1:342 N VERMONT AVE
Practice Address - Street 2:
Practice Address - City:DINUBA
Practice Address - State:CA
Practice Address - Zip Code:93618-1631
Practice Address - Country:US
Practice Address - Phone:559-591-7229
Practice Address - Fax:559-596-2085
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44707208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA29787Medicare UPIN
CA00A447070Medicare ID - Type Unspecified