Provider Demographics
NPI:1316974686
Name:SPIVACK, NORDY S (MD)
Entity type:Individual
Prefix:
First Name:NORDY
Middle Name:S
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 1:1140 W. LA VETA AVE
Mailing Address - Street 2:SUITE # 640
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4228
Mailing Address - Country:US
Mailing Address - Phone:714-564-3300
Mailing Address - Fax:714-564-3318
Practice Address - Street 1:1140 W. LA VETA AVE
Practice Address - Street 2:SUITE # 640
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4228
Practice Address - Country:US
Practice Address - Phone:714-564-3300
Practice Address - Fax:714-564-3318
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19664207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0064090Medicaid
CAG19664OtherMEDICAL LICENSE
CAG19664OtherMEDICAL LICENSE
CAA40717Medicare UPIN
CAGR0064090Medicaid