Provider Demographics
NPI:1093713356
Name:GOTLIEB, EDWARD MARVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:MARVIN
Last Name:GOTLIEB
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5405 MEMORIAL DR
Mailing Address - Street 2:BUILDING D
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3234
Mailing Address - Country:US
Mailing Address - Phone:404-296-3800
Mailing Address - Fax:404-297-8753
Practice Address - Street 1:5405 MEMORIAL DR
Practice Address - Street 2:BUILDING D
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3234
Practice Address - Country:US
Practice Address - Phone:404-296-3800
Practice Address - Fax:404-297-8753
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0145002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine