Healthcare Provider Details

I. General information

NPI: 1285693887
Provider Name (Legal Business Name): SCOTT LAWRENCE GOTTLIEB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 GORDON DR
EXTON PA
19341-1252
US

IV. Provider business mailing address

501 GORDON DRIVE
EXTON PA
19341-1252
US

V. Phone/Fax

Practice location:
  • Phone: 610-594-6660
  • Fax: 610-594-6810
Mailing address:
  • Phone: 610-594-6660
  • Fax: 610-594-6810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberBG5778379
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier070015815
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRAILROAD MEDICARE
# 2
Identifier278650
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerPENNSYLVANIA BLUE SHIELD
# 3
Identifier0584421000
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerINDEPENDENCE BLUE CROSS
# 4
Identifier2333525
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA HEALTH PLANS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: