1770161077 NPI number — DR. DAVID BENJAMIN GOOTENBERG MD, PHD

Table of content: DR. DAVID BENJAMIN GOOTENBERG MD, PHD (NPI 1770161077)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770161077 NPI number — DR. DAVID BENJAMIN GOOTENBERG MD, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOOTENBERG
Provider First Name:
DAVID
Provider Middle Name:
BENJAMIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770161077
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 CHILDRENS PL MSC 8208-0016-06
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63110-1081
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-454-6050
Provider Business Mailing Address Fax Number:
855-887-7850

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 CHILDRENS PL MSC 8208-0016-06
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63110-1081
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-454-6050
Provider Business Practice Location Address Fax Number:
855-887-7850
Provider Enumeration Date:
03/30/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 289265 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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