Provider Demographics
NPI:1861713034
Name:GOTTLIEB, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GOTTLIEB
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 1:1 RANDALL SQ
Mailing Address - Street 2:STE 205
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-2709
Mailing Address - Country:US
Mailing Address - Phone:401-331-6980
Mailing Address - Fax:401-331-8110
Practice Address - Street 1:1 RANDALL SQ
Practice Address - Street 2:STE 205
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-2709
Practice Address - Country:US
Practice Address - Phone:401-331-6980
Practice Address - Fax:401-331-8110
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCDRH.0058420207V00000X
RIMD14698207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology