1487618682 NPI number — DR. CHARLES M GOTTLICH MD

Table of content: DR. CHARLES M GOTTLICH MD (NPI 1487618682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487618682 NPI number — DR. CHARLES M GOTTLICH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOTTLICH
Provider First Name:
CHARLES
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
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:
1487618682
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16980 DALLAS PKWY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75248-1908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-391-1915
Provider Business Mailing Address Fax Number:
972-391-2061

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 N HALL ST
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75226-1339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-841-2000
Provider Business Practice Location Address Fax Number:
214-841-2015
Provider Enumeration Date:
04/14/2006

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: 207RC0000X , with the licence number:  D7059 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 129167603 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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