Provider Demographics
NPI:1417234774
Name:GOTTESMAN, BERT WALTER (MD)
Entity Type:Individual
Prefix:
First Name:BERT
Middle Name:WALTER
Last Name:GOTTESMAN
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 1:4802 12TH AVE
Mailing Address - Street 2:1B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-3072
Mailing Address - Country:US
Mailing Address - Phone:347-417-1165
Mailing Address - Fax:
Practice Address - Street 1:4802 12TH AVE
Practice Address - Street 2:1B
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-3072
Practice Address - Country:US
Practice Address - Phone:347-417-1165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-14
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY148220208D00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation