Provider Demographics
NPI:1306939723
Name:DIVACK, STEVEN MARC (MD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:MARC
Last Name:DIVACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:115 EASTERN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-6085
Mailing Address - Country:US
Mailing Address - Phone:718-638-8484
Mailing Address - Fax:718-638-8588
Practice Address - Street 1:115 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-6085
Practice Address - Country:US
Practice Address - Phone:718-638-8484
Practice Address - Fax:718-638-8588
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143879207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00523744Medicaid
NY00523744Medicaid
NYA62538Medicare UPIN