Provider Demographics
NPI:1427046614
Name:GOLDBLATT, FRED (DO)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:GOLDBLATT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2996 7TH AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302-3713
Mailing Address - Country:US
Mailing Address - Phone:319-377-4844
Mailing Address - Fax:319-377-0852
Practice Address - Street 1:2996 7TH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MARION
Practice Address - State:IA
Practice Address - Zip Code:52302-3713
Practice Address - Country:US
Practice Address - Phone:319-377-4844
Practice Address - Fax:319-377-0852
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP01270525OtherRR MEDICARE
IA1427046614Medicaid
IA719260495Medicare PIN