Provider Demographics
NPI:1841247467
Name:GOTTMAN, DIRK R (MD)
Entity type:Individual
Prefix:
First Name:DIRK
Middle Name:R
Last Name:GOTTMAN
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:PO BOX 7609
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59807-7609
Mailing Address - Country:US
Mailing Address - Phone:406-721-5600
Mailing Address - Fax:406-721-3907
Practice Address - Street 1:500 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4008
Practice Address - Country:US
Practice Address - Phone:406-721-5600
Practice Address - Fax:406-329-7131
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9637208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0028815Medicaid
MT0028815Medicaid
MT000081697Medicare ID - Type Unspecified