=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588660757
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAY STUART GOTTLIEB DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2005
-----------------------------------------------------
Last Update Date | 09/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 SW 129TH AVE STE 100
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33027-1778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-400-3376
-----------------------------------------------------
Fax | 954-217-3222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 151 SOUTHHALL LN STE 300
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-7172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-400-3376
-----------------------------------------------------
Fax | 407-650-3455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | OS4371
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------