Provider Demographics
NPI:1578569042
Name:GOTLIEB, PAUL S (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:S
Last Name:GOTLIEB
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 1:6545 CROSSTOWN AVE. S
Mailing Address - Street 2:SUITE 150
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435
Mailing Address - Country:US
Mailing Address - Phone:952-848-5600
Mailing Address - Fax:952-848-5556
Practice Address - Street 1:6545 FRANCE AVE S
Practice Address - Street 2:SUITE 150
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2131
Practice Address - Country:US
Practice Address - Phone:952-848-5600
Practice Address - Fax:952-848-5556
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0425224OtherMEDICA HEALTH PLAN
MN164202200Medicaid
MN1M593GOOtherBCBS OF MINNESOTA
MN1M593GOOtherBCBS OF MINNESOTA