MEDICARE: BERNARD GOTTLIEB MD INC

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	207ND0900X	Dermatopathology Physician	C19354	CA

General Provider Information

NPI Number	:	1679693923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BERNARD GOTTLIEB MD INC

Provider Business Mailing Address
First Line	:	PO BOX 10517
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92423-0517
Country	:	US
Telephone Number	:	888-400-0881
Fax Number	:

Provider Business Practice Location Address
First Line	:	1666 N WATERMAN AVE
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92404-5113
Country	:	US
Telephone Number	:	888-700-0881
Fax Number	:

Authorized Official
Title or Position	:	PATHOLOGIST
Name	:	DR. BERNARD GOTTLIEB
Credential	:	M.D.
Telephone Number	:	888-700-0881

Provider Enumeration Date	:	03/30/2007
Last Update Date	:	09/26/2008

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