Provider Demographics
NPI:1558540179
Name:GOTTLIEB, RICHARD MORRIS (MD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:MORRIS
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 1:57 DEDHAM AVE
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492
Mailing Address - Country:US
Mailing Address - Phone:781-449-1847
Mailing Address - Fax:781-247-7447
Practice Address - Street 1:57 DEDHAM AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492
Practice Address - Country:US
Practice Address - Phone:781-449-1847
Practice Address - Fax:781-247-7447
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA33699207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9773894Medicaid
MA9773894Medicaid
MAB73576Medicare UPIN