Provider Demographics
NPI:1407841497
Name:GOTTFRIED, JAMES A (MD)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:A
Last Name:GOTTFRIED
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 1:257 BENEDICT AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857-2715
Mailing Address - Country:US
Mailing Address - Phone:419-668-1101
Mailing Address - Fax:419-668-1191
Practice Address - Street 1:257 BENEDICT AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-2715
Practice Address - Country:US
Practice Address - Phone:419-668-1101
Practice Address - Fax:419-668-1191
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2011-05-12
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
OH35-03-8477G207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0986161Medicaid
OH0986161Medicaid
OHGO0423942Medicare PIN