Provider Demographics
NPI:1720157142
Name:GOLDBAUM, MICHAEL HENRY (MD)
Entity Type:Individual
Prefix:PROF
First Name:MICHAEL
Middle Name:HENRY
Last Name:GOLDBAUM
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:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9415 CAMPUS POINT DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1350
Practice Address - Country:US
Practice Address - Phone:858-534-3516
Practice Address - Fax:858-534-7425
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32010207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
180016079OtherRAILROAD
CA00C320100Medicaid
CAWC32010AMedicare PIN
CA00C320100Medicaid