Provider Demographics
NPI:1134441132
Name:KENT M. SIEBOLDT, OD, PA
Entity type:Organization
Organization Name:KENT M. SIEBOLDT, OD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIEBOLDT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:813-685-2646
Mailing Address - Street 1:324 E BLOOMINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8155
Mailing Address - Country:US
Mailing Address - Phone:813-685-2646
Mailing Address - Fax:813-681-6821
Practice Address - Street 1:324 E BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8155
Practice Address - Country:US
Practice Address - Phone:813-685-2646
Practice Address - Fax:813-681-6821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2120152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
20149OtherMEDICARE
FL086169300Medicaid
FL20149Medicare PIN
FL0545670002Medicare NSC
20149OtherMEDICARE