Provider Demographics
NPI:1639352958
Name:GOTTLIEB, MATTHEW PHILLIP (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:PHILLIP
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7909B NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON HTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-1223
Mailing Address - Country:US
Mailing Address - Phone:718-507-1110
Mailing Address - Fax:718-507-1530
Practice Address - Street 1:7909B NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON HTS
Practice Address - State:NY
Practice Address - Zip Code:11372-1223
Practice Address - Country:US
Practice Address - Phone:718-507-1110
Practice Address - Fax:718-507-1530
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009381111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU76439Medicare UPIN