| Doctor Name: | DR. JACK H GOTTLIEB |
| NPI Number: | 1720070840 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | 5205 |
| Business Practice Address: | 2601 Laurel St. #120 Columbia, SC - 29204 |
| Business Phone Number: | 8032547889 |
| Business Fax Number: | 8032547893 |
| Mailing Address: | 114 Gateway Corporate Blvd., #425 COLUMBIA |
| State: | SC |
| Postal Code: | 29203 |
| Phone Number: | 8038654780 |
| Fax Number: | 8038654932 |
| NPI Enumeration Date: | 08/16/2005 |
| NPI Last Update Date: | 10/30/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 5205 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | SC |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |