Healthcare Provider Details

I. General information

NPI: 1114925138
Provider Name (Legal Business Name): PHILIP D GOTTLIEB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 KENDRICK ST STE 102
NEEDHAM MA
02494-2726
US

IV. Provider business mailing address

60 KENDRICK ST STE 102
NEEDHAM MA
02494-2726
US

V. Phone/Fax

Practice location:
  • Phone: 617-244-3322
  • Fax: 617-244-1827
Mailing address:
  • Phone: 617-244-3322
  • Fax: 617-244-1827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number9803
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number014771
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number36020
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number9803
License Number StateNH
# 5
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number014771
License Number StateME
# 6
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number36020
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: