Provider Demographics
NPI:1154489847
Name:GOTTLIEB, ROBERT J (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:GOTTLIEB
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 1:45 RESEARCH WAY
Mailing Address - Street 2:STONY BROOK CHILDREN'S SERVICES, UFPC
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733
Mailing Address - Country:US
Mailing Address - Phone:631-675-2125
Mailing Address - Fax:631-675-2624
Practice Address - Street 1:5 SQUIRETOWN RD
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946
Practice Address - Country:US
Practice Address - Phone:631-728-5300
Practice Address - Fax:631-728-5360
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1442901208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01193815Medicaid
NY01193815Medicaid