Provider Demographics
NPI:1033106026
Name:GOTTLIEB, CHESTER WALTER (MD)
Entity Type:Individual
Prefix:
First Name:CHESTER
Middle Name:WALTER
Last Name:GOTTLIEB
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 1:514 N PROSPECT AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3040
Mailing Address - Country:US
Mailing Address - Phone:310-750-3300
Mailing Address - Fax:310-750-3381
Practice Address - Street 1:514 N PROSPECT AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3040
Practice Address - Country:US
Practice Address - Phone:310-750-3300
Practice Address - Fax:310-750-3381
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG6216207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G62160OtherBLUE SHIELD
WG6216BMedicare ID - Type Unspecified
A95369Medicare UPIN
00G62160OtherBLUE SHIELD