Provider Demographics
NPI:1497391817
Name:GOTTLIEB, MEGAN (DPT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 LANDING AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2749
Mailing Address - Country:US
Mailing Address - Phone:631-361-5111
Mailing Address - Fax:631-366-2536
Practice Address - Street 1:59 LANDING AVE STE 4
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2749
Practice Address - Country:US
Practice Address - Phone:631-361-5111
Practice Address - Fax:631-366-2536
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045165-01208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNAMedicaid