Provider Demographics
NPI:1972581551
Name:GOTTESMAN, MAX D (OD)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:D
Last Name:GOTTESMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6523 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-3066
Mailing Address - Country:US
Mailing Address - Phone:248-593-9955
Mailing Address - Fax:248-593-9966
Practice Address - Street 1:6523 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48301-3066
Practice Address - Country:US
Practice Address - Phone:248-593-9955
Practice Address - Fax:248-593-9966
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002384152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2721213Medicaid
MI2721222Medicaid
MIMG002384OtherBLUE CROSS
MI1972581551Medicaid
0F37720OtherMEDICARE PTAN
MI2721222Medicaid
MIF37720001Medicare PIN