Provider Demographics
NPI:1124017082
Name:GOTTLIEB, DIANE (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
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 1:2900 W QUEEN LN
Mailing Address - Street 2:SUITE 221H
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1033
Mailing Address - Country:US
Mailing Address - Phone:215-991-8532
Mailing Address - Fax:215-843-5495
Practice Address - Street 1:2900 W QUEEN LN
Practice Address - Street 2:SUITE 221H
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1033
Practice Address - Country:US
Practice Address - Phone:215-991-8532
Practice Address - Fax:215-843-5495
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD064466L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018303020006Medicaid
PA0018303020006Medicaid
F80669Medicare UPIN