Provider Demographics
NPI:1720363492
Name:GOTTLIEB, JACOB J (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:J
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 1:152 W 57TH ST
Mailing Address - Street 2:FL 20 - CO ALTIU
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 CENTRAL PARK W APT 9K
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-7713
Practice Address - Country:US
Practice Address - Phone:212-474-8810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216000207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine