Provider Demographics
NPI:1992713036
Name:GOTTLIEB, SCOTT (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
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 1:30 SHELBURNE RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3628
Mailing Address - Country:US
Mailing Address - Phone:203-276-7298
Mailing Address - Fax:203-355-4842
Practice Address - Street 1:30 SHELBURNE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3628
Practice Address - Country:US
Practice Address - Phone:203-276-7298
Practice Address - Fax:203-355-4842
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041558207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2V4161OtherHEALTH NET
CT4630381OtherAETNA - PPO
CTP3297973OtherOXFORD HEALTH PLAN
CT041558OtherEMPIRE BC/BS
CT010041558CT01OtherANTHEM BC/BS
CT3432398OtherAETNA - HMO
CT4129498OtherCONNECTICARE
CTP00209686OtherRAILROAD MEDICARE
CT4129498OtherCONNECTICARE