Healthcare Provider Details

I. General information

NPI: 1174843643
Provider Name (Legal Business Name): MARK STEVEN GOTTLIEB D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 E BROAD ST
RICHMOND VA
23223-6930
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 804-344-9848
  • Fax:
Mailing address:
  • Phone: 801-316-9620
  • Fax: 801-316-9626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS007588L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO2844
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14197633-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: