Healthcare Provider Details

I. General information

NPI: 1275581407
Provider Name (Legal Business Name): ALICE B GOTTLIEB M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 ROUTE 202 STE 2
SOMERS NY
10589-3221
US

IV. Provider business mailing address

51 TWIN LAKES RD
SOUTH SALEM NY
10590-1012
US

V. Phone/Fax

Practice location:
  • Phone: 146-178-9509
  • Fax: 914-617-8960
Mailing address:
  • Phone: 732-589-2328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number227191
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: