Provider Demographics
NPI:1619961190
Name:GOTTLIEB, SUSAN E (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:E
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 1:1 GRACE CT
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-4195
Mailing Address - Country:US
Mailing Address - Phone:718-875-8262
Mailing Address - Fax:
Practice Address - Street 1:263 7TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-7247
Practice Address - Country:US
Practice Address - Phone:718-246-8522
Practice Address - Fax:718-246-8511
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1437442080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01137879Medicaid
NY01137879Medicaid