Provider Demographics
NPI:1174843643
Name:GOTTLIEB, MARK STEVEN (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEVEN
Last Name:GOTTLIEB
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:801-316-9620
Mailing Address - Fax:801-316-9626
Practice Address - Street 1:1403 E SEGO LILY DR # 100B
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84092-4350
Practice Address - Country:US
Practice Address - Phone:801-316-9620
Practice Address - Fax:801-316-9626
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS007588L207Q00000X
NVDO2844207Q00000X
UT14197633-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009277800Medicaid
FL009277800Medicaid
FLHE267ZMedicare PIN
PA761433HK1Medicare PIN