Provider Demographics
NPI:1073573382
Name:GOTTLIEB, WENDY RUTH (MD)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:RUTH
Last Name:GOTTLIEB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 TOWN CENTER DR
Mailing Address - Street 2:SUITE 418
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-3215
Mailing Address - Country:US
Mailing Address - Phone:703-668-9499
Mailing Address - Fax:703-689-4998
Practice Address - Street 1:1800 TOWN CENTER DR
Practice Address - Street 2:SUITE 418
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3215
Practice Address - Country:US
Practice Address - Phone:703-668-9499
Practice Address - Fax:703-689-4998
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231213174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA01-00444448Medicaid
VA01-00444448Medicaid
VAG01351W01Medicare PIN