Basic Information
| Provider Information | |||||||||
| NPI: | 1952363988 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOTTLIEB | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 E SUNRISE HWY | ||||||||
| Address2: | |||||||||
| City: | LINDENHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117572539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312257200 | ||||||||
| FaxNumber: | 6319309451 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 E SUNRISE HWY | ||||||||
| Address2: | |||||||||
| City: | LINDENHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117572539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312257200 | ||||||||
| FaxNumber: | 6319309451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 06/21/2012 | ||||||||
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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 | 2085R0202X | 201697 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 02084357 | 05 | NY | MEDICAID |