Provider Demographics
NPI:1235537119
Name:LARRY J GOTTLIEB INC A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LARRY J GOTTLIEB INC A PROFESSIONAL CORPORATION
Other - Org Name:DR LARRY J GOTTLIEB OD INC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:GOTTLIEB
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-488-5472
Mailing Address - Street 1:6418 DEL AMO BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90713-2204
Mailing Address - Country:US
Mailing Address - Phone:562-420-2055
Mailing Address - Fax:562-420-1784
Practice Address - Street 1:6418 DEL AMO BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90713-2204
Practice Address - Country:US
Practice Address - Phone:562-420-2055
Practice Address - Fax:562-420-1784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6451T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty