Provider Demographics
NPI:1619937463
Name:GOTTLIEB, PAUL LENIN (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:LENIN
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 1:6620 COYLE AVE
Mailing Address - Street 2:# 301
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-6333
Mailing Address - Country:US
Mailing Address - Phone:916-961-2514
Mailing Address - Fax:916-961-0297
Practice Address - Street 1:6620 COYLE AVE
Practice Address - Street 2:# 301
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-6333
Practice Address - Country:US
Practice Address - Phone:916-961-2514
Practice Address - Fax:916-961-0297
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA26739174400000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A267390Medicaid
CA340001130OtherRAILROAD MEDICARE
CA00A267390Medicaid
CAA87086Medicare UPIN