1174529705 NPI number — DR. JOEL MARTIN GOTTLIEB I M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174529705 NPI number — DR. JOEL MARTIN GOTTLIEB I M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOTTLIEB
Provider First Name:
JOEL
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
I
Provider Credential Text:
M.D.
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:
1174529705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
66SUNSET STRIP
Provider Second Line Business Mailing Address:
STE107
Provider Business Mailing Address City Name:
SUCCASUNNA
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07876-1362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-584-4451
Provider Business Mailing Address Fax Number:
973-584-2099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
66SUNSET STRIP
Provider Second Line Business Practice Location Address:
STE107
Provider Business Practice Location Address City Name:
SUCCASUNNA
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07876-1362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-584-4451
Provider Business Practice Location Address Fax Number:
973-584-2099
Provider Enumeration Date:
06/28/2005

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:  25MA04231000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4705106 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: OK5391 . This is a "HEALTHNET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 180035676 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1027823 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: IS478 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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