MEDICARE: GOTTLIEB OPTOMETRY CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

General Provider Information

NPI Number	:	1568137669
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOTTLIEB OPTOMETRY CORPORATION

Provider Business Mailing Address
First Line	:	322 LAKEWOOD CENTER MALL
Second Line	:
City	:	LAKEWOOD
State	:	CA
Zip	:	90712-2409
Country	:	US
Telephone Number	:	562-630-2020
Fax Number	:	562-633-7220

Provider Business Practice Location Address
First Line	:	322 LAKEWOOD CENTER MALL
Second Line	:
City	:	LAKEWOOD
State	:	CA
Zip	:	90712-2409
Country	:	US
Telephone Number	:	562-630-2020
Fax Number	:	562-633-7220

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DONALD SAMUEL GOTTLIEB
Credential	:	OD
Telephone Number	:	714-454-9888

Provider Enumeration Date	:	08/11/2021
Last Update Date	:	08/11/2021

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