Provider Demographics
NPI:1407079874
Name:GOLDBAUM, IAN SAMUEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:SAMUEL
Last Name:GOLDBAUM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16244 S MILITARY TR
Mailing Address - Street 2:SUITE 290
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484-6532
Mailing Address - Country:US
Mailing Address - Phone:561-499-0033
Mailing Address - Fax:561-499-2806
Practice Address - Street 1:16244 S MILITARY TRL
Practice Address - Street 2:SUITE 290
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-6534
Practice Address - Country:US
Practice Address - Phone:561-499-0033
Practice Address - Fax:561-499-2806
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP01651213E00000X, 213ES0103X
FLPO1651213ER0200X, 213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT55583Medicare UPIN
FL87880Medicare ID - Type UnspecifiedPROVIDER NUMBER