Healthcare Provider Details

I. General information

NPI: 1245357615
Provider Name (Legal Business Name): DANIEL GOTTLIEB OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 WALNUT ST APT 302A
CHATTANOOGA TN
37403-1730
US

IV. Provider business mailing address

6300 ATLANTA HWY # 9101A
ALPHARETTA GA
30004-7821
US

V. Phone/Fax

Practice location:
  • Phone: 404-309-2020
  • Fax: 423-267-4555
Mailing address:
  • Phone: 404-309-2020
  • Fax: 423-267-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number755
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: