Healthcare Provider Details

I. General information

NPI: 1992154298
Provider Name (Legal Business Name): KIMBERLY JOY WOIDECK O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 LIELMANIS AVE
HURLBURT FIELD FL
32544-5613
US

IV. Provider business mailing address

113 LIELMANIS AVE
HURLBURT FIELD FL
32544-5613
US

V. Phone/Fax

Practice location:
  • Phone: 850-881-3918
  • Fax:
Mailing address:
  • Phone: 850-881-3918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618002498
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC5462
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD0000003419
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: