Healthcare Provider Details

I. General information

NPI: 1982601613
Provider Name (Legal Business Name): TODD A GOLDBLUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 MULBERRY NE
ALBUQUERQUE NM
87106
US

IV. Provider business mailing address

303 MULBERRY NE
ALBUQUERQUE NM
87106
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-9739
  • Fax: 505-243-9739
Mailing address:
  • Phone: 505-243-9739
  • Fax: 505-842-0650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number9562
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number95-62
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: