Provider Demographics
NPI:1720185515
Name:GOTTLIEB, SCOTT LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:LAWRENCE
Last Name:GOTTLIEB
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:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:10965-0146
Mailing Address - Country:US
Mailing Address - Phone:845-368-0800
Mailing Address - Fax:845-368-0810
Practice Address - Street 1:67 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PEARL RIVER
Practice Address - State:NY
Practice Address - Zip Code:10965-2444
Practice Address - Country:US
Practice Address - Phone:845-368-0800
Practice Address - Fax:845-368-0810
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA081193207LP2900X
NY231296-1207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI26388Medicare UPIN