Provider Demographics
NPI:1700990942
Name:GOTTLIEB, CHARLENE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLENE
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 BONHOMME AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-3515
Mailing Address - Country:US
Mailing Address - Phone:314-725-8220
Mailing Address - Fax:
Practice Address - Street 1:8000 BONHOMME AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-3515
Practice Address - Country:US
Practice Address - Phone:314-725-8220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6417207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA28168Medicare UPIN