Provider Demographics
NPI:1114925138
Name:GOTTLIEB, PHILIP D (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:D
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:60 KENDRICK ST
Mailing Address - Street 2:STE 102
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-2726
Mailing Address - Country:US
Mailing Address - Phone:617-244-3322
Mailing Address - Fax:617-244-1827
Practice Address - Street 1:60 KENDRICK ST
Practice Address - Street 2:STE 102
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-2726
Practice Address - Country:US
Practice Address - Phone:617-244-3322
Practice Address - Fax:617-244-1827
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH98032084P0800X, 2084P0805X
ME0147712084P0800X, 2084P0805X
MA360202084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM08983OtherBLUE CROSS AND BLUE SHIEL
MA0180653Medicaid
NH3112961Medicaid
MAM08983Medicare ID - Type Unspecified