Provider Demographics
NPI:1285007112
Name:KENNETH P. GOLDBLUM, M.D., LTD.
Entity Type:Organization
Organization Name:KENNETH P. GOLDBLUM, M.D., LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:P
Authorized Official - Last Name:GOLDBLUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-205-2917
Mailing Address - Street 1:26 TIERRA MONTE ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-2102
Mailing Address - Country:US
Mailing Address - Phone:505-453-6554
Mailing Address - Fax:
Practice Address - Street 1:26 TIERRA MONTE ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-2102
Practice Address - Country:US
Practice Address - Phone:505-453-6554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM71-145207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty