Basic Information
| Provider Information | |||||||||
| NPI: | 1588660757 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOTTLIEB | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | STUART | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1951 SW 172ND AVE | ||||||||
| Address2: | STE 416 | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330295615 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1951 SW 172ND AVE | ||||||||
| Address2: | STE 416 | ||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330295615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544473200 | ||||||||
| FaxNumber: | 9544473205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 01/22/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | OS4371 | FL | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.