Basic Information
| Provider Information | |||||||||
| NPI: | 1619961190 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOTTLIEB | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M..D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GRACE CT | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112014195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188758262 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 AMITY ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112016107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187801014 | ||||||||
| FaxNumber: | 7187802849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0006X | 143744 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 01137879 | 05 | NY | MEDICAID |