Provider Demographics
NPI:1710123112
Name:KENNETH I. GOTTLIEB, M.D. A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:KENNETH I. GOTTLIEB, M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:I
Authorized Official - Last Name:GOTTLIEB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-346-2103
Mailing Address - Street 1:909 HYDE ST STE 430
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-4846
Mailing Address - Country:US
Mailing Address - Phone:415-346-2103
Mailing Address - Fax:
Practice Address - Street 1:909 HYDE ST STE 430
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-4846
Practice Address - Country:US
Practice Address - Phone:415-346-2103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG230132084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic PsychiatryGroup - Single Specialty