# KENT M. SIEBOLDT, OD, PA

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1134441132
- **Authorized official:** KENT M. SIEBOLDT OD (PRESIDENT)
- **Authorized official phone:** (813) 685-2646

## Contact information

- **Practice address:** 324 E BLOOMINGDALE AVE, BRANDON, FL 33511-8155
- **Practice address phone:** (813) 685-2646
- **Practice address fax:** (813) 681-6821
- **Mailing address:** 324 E BLOOMINGDALE AVE, BRANDON, FL 33511-8155
- **Mailing address phone:** (813) 685-2646
- **Mailing address fax:** (813) 681-6821

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 152W00000X | Optometrist | 2120 | FL | Yes |

## Other

- **Enumeration date:** 02/18/2010
- **Last updated:** 02/18/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 086169300 | — | FL |
| 01 | — | 20149 | MEDICARE | — |