Provider Demographics
NPI:1417905985
Name:GOTTFRIED, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
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 1:3131 PRINCETON PIKE
Mailing Address - Street 2:BLDG 5 SUITE 208
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648
Mailing Address - Country:US
Mailing Address - Phone:609-815-7829
Mailing Address - Fax:609-815-7894
Practice Address - Street 1:66 W GILBERT ST
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07701-4947
Practice Address - Country:US
Practice Address - Phone:732-212-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02885300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0106844Medicaid
NJ0106844Medicaid
E55043Medicare UPIN
NJ102126M5NMedicare PIN
NJ102126XPFMedicare PIN