Provider Demographics
NPI:1801873336
Name:SPIVAK, ANNA SR
Entity type:Individual
Prefix:MRS
First Name:ANNA
Middle Name:
Last Name:SPIVAK
Suffix:SR
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 S FAIRFAX AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-3148
Mailing Address - Country:US
Mailing Address - Phone:323-933-0363
Mailing Address - Fax:323-933-0363
Practice Address - Street 1:425 S FAIRFAX AVE
Practice Address - Street 2:STE 202
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-3148
Practice Address - Country:US
Practice Address - Phone:323-933-0363
Practice Address - Fax:323-933-0363
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA3437174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA0034370Medicaid