Provider Demographics
NPI:1336688720
Name:KIDSEYEDR, LLC
Entity Type:Organization
Organization Name:KIDSEYEDR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NEHEMIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-249-1038
Mailing Address - Street 1:915 SE OCEAN BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2426
Mailing Address - Country:US
Mailing Address - Phone:772-249-1038
Mailing Address - Fax:
Practice Address - Street 1:915 SE OCEAN BLVD STE 4
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2426
Practice Address - Country:US
Practice Address - Phone:772-249-1038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-17
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001380900Medicaid
1528219292Medicare UPIN