Provider Demographics
NPI:1366438475
Name:SPIVACK, SIMON DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:SIMON
Middle Name:DANIEL
Last Name:SPIVACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1300 MORRIS PARK AVE
Mailing Address - Street 2:PULMONARY MEDICINE
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-1900
Mailing Address - Country:US
Mailing Address - Phone:718-430-2591
Mailing Address - Fax:718-430-8563
Practice Address - Street 1:1300 MORRIS PARK AVE
Practice Address - Street 2:PULMONARY MEDICINE
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1900
Practice Address - Country:US
Practice Address - Phone:718-430-2591
Practice Address - Fax:718-430-8563
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY189782-1207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01269763Medicaid
NY35183SMedicare ID - Type Unspecified
NYE75666Medicare UPIN