Basic Information
| Provider Information | |||||||||
| NPI: | 1376539148 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOTTLIEB | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 280 W MACARTHUR BLVD | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946115642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107521000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 280 W MACARTHUR BLVD | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946115642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107527667 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 309334 | CA | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LX0001X | 309334 | CA | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 309334 | 01 | CA | RN LICENSE NUMBER | OTHER | 3903 | 01 | CA | NP FURNISHING NUMBER | OTHER |