Healthcare Provider Details

I. General information

NPI: 1285007112
Provider Name (Legal Business Name): KENNETH P. GOLDBLUM, M.D., LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 TIERRA MONTE ST NE
ALBUQUERQUE NM
87122-2102
US

IV. Provider business mailing address

26 TIERRA MONTE ST NE
ALBUQUERQUE NM
87122-2102
US

V. Phone/Fax

Practice location:
  • Phone: 505-453-6554
  • Fax:
Mailing address:
  • Phone: 505-453-6554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number71-145
License Number StateNM

VIII. Authorized Official

Name: DR. KENNETH P. GOLDBLUM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 505-205-2917