Provider Demographics
NPI:1609900653
Name:GOTTLIEB, LARRY JAY (OD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:JAY
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6418 DEL AMO BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90713-2204
Mailing Address - Country:US
Mailing Address - Phone:562-420-2055
Mailing Address - Fax:562-420-1784
Practice Address - Street 1:6418 DEL AMO BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90713-2204
Practice Address - Country:US
Practice Address - Phone:562-420-2055
Practice Address - Fax:562-420-1784
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6451T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU68216Medicare UPIN