Provider Demographics
NPI:1770684375
Name:GOTTESMAN, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
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 1:7580 FANNIN
Mailing Address - Street 2:#330
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054
Mailing Address - Country:US
Mailing Address - Phone:713-797-0060
Mailing Address - Fax:713-791-1630
Practice Address - Street 1:7580 FANNIN
Practice Address - Street 2:#330
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054
Practice Address - Country:US
Practice Address - Phone:713-797-0060
Practice Address - Fax:713-791-1630
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1597207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123887504Medicaid
TX123887505Medicaid
SY93OtherBCBS
B23090Medicare UPIN
TX123887504Medicaid
00SY93Medicare ID - Type Unspecified
TX8L24456Medicare PIN