MEDICARE: KEVIN K. NIEBAUM D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	047353	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760449383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN K. NIEBAUM D.O.

Provider Business Mailing Address
First Line	:	2080 CHILD ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32214-3600
Country	:	US
Telephone Number	:	904-542-9703
Fax Number	:	904-542-9483

Provider Business Practice Location Address
First Line	:	2080 CHILD ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32214-3647
Country	:	US
Telephone Number	:	904-542-9703
Fax Number	:	904-542-9483

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2006
Last Update Date	:	02/06/2025

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