Basic Information
| Provider Information | |||||||||
| NPI: | 1609987213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOTTUS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JAY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 ELM PL | ||||||||
| Address2: | |||||||||
| City: | RED BANK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077011917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323838210 | ||||||||
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| Practice Location | |||||||||
| Address1: | 425 JACK MARTIN BLVD | ||||||||
| Address2: | |||||||||
| City: | BRICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087247732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328403380 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 10/12/2007 | ||||||||
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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 | 363A00000X | 25MP00179400 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.