Provider Demographics
NPI:1750333217
Name:GOTTLIEB, MONIKA A (MD)
Entity Type:Individual
Prefix:DR
First Name:MONIKA
Middle Name:A
Last Name:GOTTLIEB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2671 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-1725
Mailing Address - Country:US
Mailing Address - Phone:805-242-1141
Mailing Address - Fax:805-254-0408
Practice Address - Street 1:2671 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-1725
Practice Address - Country:US
Practice Address - Phone:805-242-1141
Practice Address - Fax:805-254-0408
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037805207R00000X, 208M00000X
IDM10447208M00000X
CA166839207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8453441Medicaid
NCP00351556OtherRR MCARE
NC8453441Medicaid
NC8859994Medicare PIN