Provider Demographics
NPI:1295733137
Name:SIEBOLDT, KENT M (OD)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:M
Last Name:SIEBOLDT
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 1:324 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
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2120152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL086169300Medicaid
FL0545670002Medicare NSC
FL086169300Medicaid
FL20149Medicare ID - Type Unspecified