Provider Demographics
NPI:1720085889
Name:GOLDBLUM, KENNETH PAUL (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:PAUL
Last Name:GOLDBLUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 MULBERRY NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106
Mailing Address - Country:US
Mailing Address - Phone:505-243-9739
Mailing Address - Fax:505-842-0650
Practice Address - Street 1:303 MULBERRY NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-243-9739
Practice Address - Fax:505-842-0650
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM145207W00000X
NM71-145207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2120562Medicare ID - Type Unspecified
NMC97798Medicare UPIN