Provider Demographics
NPI:1902857303
Name:GOTTESMAN, DEMOCLEIA (MD)
Entity Type:Individual
Prefix:DR
First Name:DEMOCLEIA
Middle Name:
Last Name:GOTTESMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 OCEAN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-6828
Mailing Address - Country:US
Mailing Address - Phone:718-934-4842
Mailing Address - Fax:781-616-0165
Practice Address - Street 1:415 OCEAN VIEW AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6828
Practice Address - Country:US
Practice Address - Phone:718-934-4842
Practice Address - Fax:781-616-0165
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181011207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01356463Medicaid
NY01356463Medicaid
F29441Medicare UPIN
07402Medicare ID - Type UnspecifiedGHI MEDICARE