Provider Demographics
NPI:1265430524
Name:GOTTLIEB, IRA J (DPM)
Entity type:Individual
Prefix:DR
First Name:IRA
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 1:8030B RITCHIE HWY
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-1084
Mailing Address - Country:US
Mailing Address - Phone:410-761-0118
Mailing Address - Fax:410-761-5118
Practice Address - Street 1:8030B RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-1084
Practice Address - Country:US
Practice Address - Phone:410-761-0118
Practice Address - Fax:410-761-5118
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00973213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD437198400Medicaid
MD437198400Medicaid
MDT59880Medicare UPIN
MD226505YFCHMedicare PIN