1083677389 NPI number — MALCOLM H GOTTESMAN MD

Table of content: MALCOLM H GOTTESMAN MD (NPI 1083677389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083677389 NPI number — MALCOLM H GOTTESMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOTTESMAN
Provider First Name:
MALCOLM
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1083677389
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 OLD COUNTRY RD
Provider Second Line Business Mailing Address:
SUITE 370
Provider Business Mailing Address City Name:
MINEOLA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11501-4235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1530 FRONT ST STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST MEADOW
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11554-2265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-324-7500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/08/2006

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: 174400000X , with the licence number:  166564 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 108754 . This is a "US FAMILY HEALTHPLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: OC6883 . This is a "HEALTH NET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 100806 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4269008 . This is a "AETNA USHC (PPO)" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0006491 . This is a "GHI (CBP)" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1305413 . This is a "FIRST HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: AS1190 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0489698 . This is a "AETNA USHC(HMO,FAMILY)" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 166564-5 . This is a "WORKER'S COMPENSATION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 36E651 . This is a "BLUE CHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000073359 . This is a "GHI (HMO)" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01110970 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 166564 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 6216385003 . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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