Provider Demographics
NPI:1295115012
Name:GOTTERT, NICHOLAS (DO)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GOTTERT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 W MAIN ST STE 301
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-1758
Mailing Address - Country:US
Mailing Address - Phone:626-457-6900
Mailing Address - Fax:
Practice Address - Street 1:336 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33128-1616
Practice Address - Country:US
Practice Address - Phone:305-577-4840
Practice Address - Fax:305-373-7431
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-06
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A17055207Q00000X
FLOS16567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine