Provider Demographics
NPI:1336132968
Name:GOTLIEB, JERRY (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:GOTLIEB
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 1:1313 DEKALB ST
Mailing Address - Street 2:
Mailing Address - City:NORRISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19401-3403
Mailing Address - Country:US
Mailing Address - Phone:610-272-1881
Mailing Address - Fax:610-275-8819
Practice Address - Street 1:1313 DEKALB ST
Practice Address - Street 2:
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19401-3403
Practice Address - Country:US
Practice Address - Phone:610-272-1881
Practice Address - Fax:610-275-8819
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD007482E208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006467000001Medicaid
PAB33194Medicare UPIN
PA018731Medicare ID - Type Unspecified