Provider Demographics
NPI:1073551735
Name:FEDER, KIMBERLY B (OD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:B
Last Name:FEDER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:B
Other - Last Name:NINYO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 61199
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33906-1199
Mailing Address - Country:US
Mailing Address - Phone:239-418-0999
Mailing Address - Fax:239-418-0091
Practice Address - Street 1:12731 NEW BRITTANY BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3632
Practice Address - Country:US
Practice Address - Phone:239-418-0999
Practice Address - Fax:239-418-0091
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4043152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001974600Medicaid
FLU8665ZMedicare PIN
FL001974600Medicaid