1588660757 NPI number — DR. JAY STUART GOTTLIEB DO

Table of content: DR. JAY STUART GOTTLIEB DO (NPI 1588660757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588660757 NPI number — DR. JAY STUART GOTTLIEB DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOTTLIEB
Provider First Name:
JAY
Provider Middle Name:
STUART
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1588660757
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
151 SOUTHHALL LN STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAITLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32751-7172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-400-3376
Provider Business Mailing Address Fax Number:
407-650-3455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 SW 129TH AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEMBROKE PINES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33027-1778
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-400-3376
Provider Business Practice Location Address Fax Number:
954-217-3222
Provider Enumeration Date:
06/22/2005

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: 207N00000X , with the licence number:  OS4371 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 103958800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com