Provider Demographics
NPI:1588743041
Name:GOLDENBAUM, WALTER CARL (DPM)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:CARL
Last Name:GOLDENBAUM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 SALOMONE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-3348
Mailing Address - Country:US
Mailing Address - Phone:973-925-8662
Mailing Address - Fax:
Practice Address - Street 1:424 E 138TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454-3002
Practice Address - Country:US
Practice Address - Phone:718-665-6116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004615213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01197442Medicaid
NYP53282Medicare ID - Type UnspecifiedPROVIDER NUMBER
NY01197442Medicaid