Provider Demographics
NPI:1235260027
Name:GOTTLIEB, ROY (DC)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SHORE HILL RD
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-1763
Mailing Address - Country:US
Mailing Address - Phone:978-436-0992
Mailing Address - Fax:
Practice Address - Street 1:22 SHORE HILL RD
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-1763
Practice Address - Country:US
Practice Address - Phone:978-436-0992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA452111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY35367OtherMASS BCBS