Provider Demographics
NPI:1639158538
Name:GOTTLICH, MALCOLM D (MD)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:D
Last Name:GOTTLICH
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 1:1075 MASON AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117
Mailing Address - Country:US
Mailing Address - Phone:386-255-4596
Mailing Address - Fax:386-258-3561
Practice Address - Street 1:1075 MASON AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117
Practice Address - Country:US
Practice Address - Phone:386-255-4596
Practice Address - Fax:386-258-3561
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57439207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007653200Medicaid
FL007653200Medicaid
FL0340420001Medicare NSC
FL25458ZMedicare PIN