Provider Demographics
NPI:1306808894
Name:GOTTLIEB, STEPHEN S (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:S
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-8788
Mailing Address - Fax:410-328-1048
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-8788
Practice Address - Fax:410-328-1048
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD36885207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC034324800Medicaid
MD529997-01OtherBLUE CROSS/BLUE SHIELD
DE1306808894Medicaid
VA5849721Medicaid
MD294261500Medicaid
WV0195000000Medicaid
OH2292068Medicaid
A60047Medicare UPIN
OH2292068Medicaid
MDS083R247Medicare PIN