Provider Demographics
NPI:1811979842
Name:GOTTLIEB, JAMIE EDEN (MD)
Entity type:Individual
Prefix:MR
First Name:JAMIE
Middle Name:EDEN
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8528 DAVIS BLVD STE 134
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76182-8302
Mailing Address - Country:US
Mailing Address - Phone:469-528-1169
Mailing Address - Fax:
Practice Address - Street 1:6121 HWY 161
Practice Address - Street 2:SUITE 225
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038
Practice Address - Country:US
Practice Address - Phone:469-528-1169
Practice Address - Fax:877-319-1790
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059066A207XS0117X
TXK9790207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000567134OtherANTHEM BCBS
IN256940AMedicare PIN
IN000000567134OtherANTHEM BCBS