Provider Demographics
NPI:1396843876
Name:GOTBAUM, IRWIN (DO)
Entity Type:Individual
Prefix:
First Name:IRWIN
Middle Name:
Last Name:GOTBAUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:LAKE HELEN
Mailing Address - State:FL
Mailing Address - Zip Code:32744-3503
Mailing Address - Country:US
Mailing Address - Phone:386-228-2451
Mailing Address - Fax:
Practice Address - Street 1:137 WILLOW DR
Practice Address - Street 2:
Practice Address - City:LAKE HELEN
Practice Address - State:FL
Practice Address - Zip Code:32744-3121
Practice Address - Country:US
Practice Address - Phone:386-228-2755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 16542085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD27308Medicare UPIN
FLE5781Medicare ID - Type Unspecified