Provider Demographics
NPI:1790013597
Name:ROBERT J. GOTTLIEB, DPM, PC
Entity Type:Organization
Organization Name:ROBERT J. GOTTLIEB, DPM, PC
Other - Org Name:ROBERT J. GOTTLIEB, DPM, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BUDNICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-922-0502
Mailing Address - Street 1:46 LITTLE EAST NECK RD
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-2509
Mailing Address - Country:US
Mailing Address - Phone:631-321-6704
Mailing Address - Fax:631-321-1715
Practice Address - Street 1:46 LITTLE EAST NECK RD
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-2509
Practice Address - Country:US
Practice Address - Phone:631-321-6704
Practice Address - Fax:631-321-1715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN002806213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW42121Medicare PIN