Provider Demographics
NPI:1023199478
Name:GOTTLIEB, STEWART (OD)
Entity Type:Individual
Prefix:DR
First Name:STEWART
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 ARGYLE RD
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-1234
Mailing Address - Country:US
Mailing Address - Phone:516-791-0033
Mailing Address - Fax:515-791-0033
Practice Address - Street 1:453 ARGYLE RD
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516-1234
Practice Address - Country:US
Practice Address - Phone:516-791-0033
Practice Address - Fax:515-791-0033
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT002895-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00350330Medicaid
NY03427Medicare ID - Type UnspecifiedGHI MEDICARE
NYC51401Medicare ID - Type UnspecifiedEMPIRE BC/BS MEDICARE
NYU14277Medicare UPIN