Provider Demographics
NPI:1891912135
Name:GOTTLIEB, FRED (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3170 ANTELO RD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1604
Mailing Address - Country:US
Mailing Address - Phone:310-472-5551
Mailing Address - Fax:310-472-9225
Practice Address - Street 1:3586 S BENTLEY AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-6505
Practice Address - Country:US
Practice Address - Phone:310-839-4714
Practice Address - Fax:310-839-7845
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA187042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry