Provider Demographics
NPI:1043292980
Name:GOTTLIEB, JEFFREY H (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:H
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 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-344-6760
Mailing Address - Fax:860-358-4829
Practice Address - Street 1:28 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3654
Practice Address - Country:US
Practice Address - Phone:860-344-6760
Practice Address - Fax:860-358-4829
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0280082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT11280080Medicaid
CT260004270Medicare ID - Type Unspecified
CT11280080Medicaid