Provider Demographics
NPI:1750709978
Name:LIEB, GWENDOLYN Z (MD)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:Z
Last Name:LIEB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:Z
Other - Last Name:GOTTLIEB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:900 5TH AVE S UNIT 100
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-4036
Mailing Address - Country:US
Mailing Address - Phone:206-660-0395
Mailing Address - Fax:
Practice Address - Street 1:1717 W COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5926
Practice Address - Country:US
Practice Address - Phone:907-451-6682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60469767208000000X
AK121743208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics