Healthcare Provider Details

I. General information

NPI: 1427046614
Provider Name (Legal Business Name): FRED GOLDBLATT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2996 7TH AVE SUITE B
MARION IA
52302-3713
US

IV. Provider business mailing address

2996 7TH AVE SUITE B
MARION IA
52302-3713
US

V. Phone/Fax

Practice location:
  • Phone: 319-377-4844
  • Fax: 319-377-0852
Mailing address:
  • Phone: 319-377-4844
  • Fax: 319-377-0852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02020
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: