Healthcare Provider Details

I. General information

NPI: 1104155159
Provider Name (Legal Business Name): DAVID M GOTTESMAN MEDICAL DOCTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2009
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 FISH HOLLOW RD
NORTH CREEK NY
12853-3502
US

IV. Provider business mailing address

104 FISH HOLLOW RD
NORTH CREEK NY
12853-3502
US

V. Phone/Fax

Practice location:
  • Phone: 518-494-5044
  • Fax: 518-494-5044
Mailing address:
  • Phone: 518-494-5044
  • Fax: 518-494-5044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number099114
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: