Provider Demographics
NPI:1588660757
Name:GOTTLIEB, JAY STUART (DO)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:STUART
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 SOUTHHALL LN STE 300
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7172
Mailing Address - Country:US
Mailing Address - Phone:866-400-3376
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:3 SW 129TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1778
Practice Address - Country:US
Practice Address - Phone:866-400-3376
Practice Address - Fax:954-217-3222
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4371207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD60642Medicare UPIN
FL82445Medicare ID - Type Unspecified