Provider Demographics
NPI:1508071671
Name:NIEDERMAN, NEAL ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:NEAL
Middle Name:ALAN
Last Name:NIEDERMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:989 TAHOE KEYS BLVD
Mailing Address - Street 2:#4
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-7141
Mailing Address - Country:US
Mailing Address - Phone:530-544-9752
Mailing Address - Fax:
Practice Address - Street 1:989 TAHOE KEYS BLVD
Practice Address - Street 2:#4
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7141
Practice Address - Country:US
Practice Address - Phone:530-544-9752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5190 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist