Provider Demographics
NPI:1760449383
Name:NIEBAUM, KEVIN K (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:K
Last Name:NIEBAUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 CHILD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214-3600
Mailing Address - Country:US
Mailing Address - Phone:904-542-9703
Mailing Address - Fax:904-542-9483
Practice Address - Street 1:2080 CHILD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-3647
Practice Address - Country:US
Practice Address - Phone:904-542-9703
Practice Address - Fax:904-542-9483
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047353208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000834809DMedicaid
H09875Medicare UPIN