Provider Demographics
NPI:1538331210
Name:IAN S GOLDBAUM DPM PA
Entity Type:Organization
Organization Name:IAN S GOLDBAUM DPM PA
Other - Org Name:IAN S GOLDBAUM DPM PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOLDBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:561-499-0033
Mailing Address - Street 1:16244 S MILITARY TRL
Mailing Address - Street 2:SUITE 290
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484-6534
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP01651261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL87880Medicare PIN
FL1128970001Medicare NSC