Healthcare Provider Details

I. General information

NPI: 1093713356
Provider Name (Legal Business Name): EDWARD MARVIN GOTLIEB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 MEMORIAL DR BUILDING D
STONE MOUNTAIN GA
30083-3234
US

IV. Provider business mailing address

5405 MEMORIAL DR BUILDING D
STONE MOUNTAIN GA
30083-3234
US

V. Phone/Fax

Practice location:
  • Phone: 404-296-3800
  • Fax: 404-297-8753
Mailing address:
  • Phone: 404-296-3800
  • Fax: 404-297-8753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number014500
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: