Provider Demographics
NPI:1922002716
Name:GOTTLIEB, ROBERT J (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OYSTER BAY
Mailing Address - State:NY
Mailing Address - Zip Code:11771-2229
Mailing Address - Country:US
Mailing Address - Phone:516-922-0502
Mailing Address - Fax:516-922-0289
Practice Address - Street 1:188 W MAIN ST
Practice Address - Street 2:
Practice Address - City:OYSTER BAY
Practice Address - State:NY
Practice Address - Zip Code:11771-2229
Practice Address - Country:US
Practice Address - Phone:516-922-0502
Practice Address - Fax:516-922-0289
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2013-11-08
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
NYN002806213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP310942121Medicare PIN
NYT50877Medicare UPIN