Basic Information
Provider Information | |||||||||
NPI: | 1811979842 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOTTLIEB | ||||||||
FirstName: | JAMIE | ||||||||
MiddleName: | EDEN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8528 DAVIS BLVD STE 134 | ||||||||
Address2: |   | ||||||||
City: | NORTH RICHLAND HILLS | ||||||||
State: | TX | ||||||||
PostalCode: | 761828302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4695281169 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6121 HWY 161 | ||||||||
Address2: | SUITE 225 | ||||||||
City: | IRVING | ||||||||
State: | TX | ||||||||
PostalCode: | 75038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4695281169 | ||||||||
FaxNumber: | 8773191790 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2005 | ||||||||
LastUpdateDate: | 10/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | 01059066A | IN | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XS0117X | K9790 | TX | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
ID Information
ID | Type | State | Issuer | Description | 000000567134 | 01 | IN | ANTHEM BCBS | OTHER |