Provider Demographics
NPI:1891288676
Name:GOTTESMAN MEDICAL PC
Entity type:Organization
Organization Name:GOTTESMAN MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:AVRAHAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOTTESMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-757-8751
Mailing Address - Street 1:555 LEFFERTS AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-4543
Mailing Address - Country:US
Mailing Address - Phone:646-757-8751
Mailing Address - Fax:877-885-5991
Practice Address - Street 1:555 LEFFERTS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-4543
Practice Address - Country:US
Practice Address - Phone:646-757-8751
Practice Address - Fax:877-885-5991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-07
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY242626207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03029178Medicaid