Provider Demographics
NPI:1245357615
Name:GOTTLIEB, DANIEL (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:GOTTLIEB
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 1:6300 ATLANTA HWY # 9101A
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-7821
Mailing Address - Country:US
Mailing Address - Phone:404-309-2020
Mailing Address - Fax:423-267-4555
Practice Address - Street 1:318 WALNUT ST APT 302A
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-1730
Practice Address - Country:US
Practice Address - Phone:404-309-2020
Practice Address - Fax:423-267-4555
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA755152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA81456068Medicare ID - Type Unspecified
GAT97603Medicare UPIN