Provider Demographics
NPI:1821132119
Name:GOTTLIEB, JONATHAN ELI (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ELI
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 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-6858
Mailing Address - Fax:410-328-8664
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-6858
Practice Address - Fax:410-328-8664
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD27968207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD305402101Medicaid
MD952931-01 & 02OtherBLUE CROSS/BLUE SHIELD
MDS062-0363OtherBLUE CROSS/BLUE SHIELD - REGIONAL
MD305402101Medicaid
C29250Medicare UPIN