Provider Demographics
NPI:1891789541
Name:GOTTLIEB, PHILIP D (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:D
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 1:5 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901-2322
Mailing Address - Country:US
Mailing Address - Phone:607-772-9462
Mailing Address - Fax:607-772-1223
Practice Address - Street 1:169 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4246
Practice Address - Country:US
Practice Address - Phone:607-798-5223
Practice Address - Fax:607-798-5187
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1347012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01086704Medicaid
NYRA4733Medicare ID - Type Unspecified
NY01086704Medicaid