Healthcare Provider Details

I. General information

NPI: 1407079874
Provider Name (Legal Business Name): IAN SAMUEL GOLDBAUM D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16244 S MILITARY TRL SUITE 290
DELRAY BEACH FL
33484-6534
US

IV. Provider business mailing address

16244 S MILITARY TR SUITE 290
DELRAY BEACH FL
33484-6532
US

V. Phone/Fax

Practice location:
  • Phone: 561-499-0033
  • Fax: 561-499-2806
Mailing address:
  • Phone: 561-499-0033
  • Fax: 561-499-2806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberP01651
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License NumberPO1651
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberPO1651
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberP01651
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: