Provider Demographics
NPI:1679689103
Name:GOTTESMAN, MARTIN JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:JAY
Last Name:GOTTESMAN
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 1:931 CHATHAM LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-2417
Mailing Address - Country:US
Mailing Address - Phone:614-451-3643
Mailing Address - Fax:
Practice Address - Street 1:931 CHATHAM LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-2417
Practice Address - Country:US
Practice Address - Phone:614-451-3643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH041176207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH310748669026Medicaid
A80371Medicare UPIN
GO0513791Medicare ID - Type Unspecified