Provider Demographics
NPI:1871506808
Name:GOTTLIEB, MICHAEL STUART (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STUART
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 1:1613 CHELSEA RD
Mailing Address - Street 2:#334
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-1812
Mailing Address - Country:US
Mailing Address - Phone:626-281-3255
Mailing Address - Fax:626-281-0820
Practice Address - Street 1:5901 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 401
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4667
Practice Address - Country:US
Practice Address - Phone:323-954-1073
Practice Address - Fax:323-954-1081
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
CAG34195207R00000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G341950Medicaid
F07502Medicare UPIN
CA00G341950Medicaid
CAG34195F, G34195GMedicare ID - Type Unspecified