Provider Demographics
NPI:1609858075
Name:GOTTLIEB, MICHAEL MILTON (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:MILTON
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 1:1320 EL CAPITAN DR STE 120
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-6260
Mailing Address - Country:US
Mailing Address - Phone:925-676-2600
Mailing Address - Fax:925-680-0212
Practice Address - Street 1:1320 EL CAPITAN DR
Practice Address - Street 2:SUITE 440
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-6258
Practice Address - Country:US
Practice Address - Phone:925-277-1117
Practice Address - Fax:925-277-1119
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70422208C00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
20-1426034OtherTAX ID #