Provider Demographics
NPI:1275521635
Name:GOTTLIEB, MARC E (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:E
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 1:1012 E WILLETTA STREET
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006
Mailing Address - Country:US
Mailing Address - Phone:602-839-6040
Mailing Address - Fax:602-839-4375
Practice Address - Street 1:1012 E WILLETTA STREET
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006
Practice Address - Country:US
Practice Address - Phone:602-839-6040
Practice Address - Fax:602-839-4375
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ200392086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ053025Medicaid
A50979Medicare UPIN
AZ053025Medicaid