Provider Demographics
NPI:1083677389
Name:GOTTESMAN, MALCOLM H (MD)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:H
Last Name:GOTTESMAN
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 1:200 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 370
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1530 FRONT ST STE 400
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-2265
Practice Address - Country:US
Practice Address - Phone:516-324-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166564174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY108754OtherUS FAMILY HEALTHPLAN
NYOC6883OtherHEALTH NET
NY100806OtherUNITED HEALTHCARE
NY4269008OtherAETNA USHC (PPO)
NY0006491OtherGHI (CBP)
NY1305413OtherFIRST HEALTH
NYAS1190OtherOXFORD
NY0489698OtherAETNA USHC(HMO,FAMILY)
NY166564-5OtherWORKER'S COMPENSATION
NY36E651OtherBLUE CHOICE
NY000000073359OtherGHI (HMO)
NY01110970Medicaid
NY166564OtherHIP
NY6216385003OtherCIGNA
NY6216385003OtherCIGNA
NYBG1383176OtherDEA
NYB73798Medicare UPIN
NY1305413OtherFIRST HEALTH
NY166564OtherHIP