Provider Demographics
NPI:1205891413
Name:GOTTLIEB, RICHARD T (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:T
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 1:15615 N 71ST STREET
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254
Mailing Address - Country:US
Mailing Address - Phone:602-494-8105
Mailing Address - Fax:602-494-8108
Practice Address - Street 1:15615 N 71ST STREET
Practice Address - Street 2:SUITE 108
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254
Practice Address - Country:US
Practice Address - Phone:602-494-8105
Practice Address - Fax:602-494-8108
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ160892084P0800X
CAG513692084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0390690OtherBLUE CROSS / BLUE SHIELD
AZ42730OtherMHN
AZ38334430OtherUNITED HEALTHCARE
AZ42730OtherMHN