Provider Demographics
NPI:1568488161
Name:GOTTLIEB, MICHELE J (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:J
Last Name:GOTTLIEB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1215
Mailing Address - Country:US
Mailing Address - Phone:508-481-5500
Mailing Address - Fax:508-481-3706
Practice Address - Street 1:24 NEWTON ST
Practice Address - Street 2:
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-1215
Practice Address - Country:US
Practice Address - Phone:508-481-5500
Practice Address - Fax:508-481-3706
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA742502080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3111873Medicaid
MAD76240Medicare UPIN
MAJ11312Medicare ID - Type Unspecified