Basic Information
| Provider Information | |||||||||
| NPI: | 1417905985 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOTTFRIED | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 PRINCETON PIKE | ||||||||
| Address2: | BLDG 5 SUITE 208 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098157829 | ||||||||
| FaxNumber: | 6098157894 | ||||||||
| Practice Location | |||||||||
| Address1: | 66 W GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | TINTON FALLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077014947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322120060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 10/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MA02885300 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0106844 | 05 | NJ | MEDICAID |