Kevin K. Niebaum, D.O.

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

047353 Issued in GA

Practice address

2080 Child St
Jacksonville, FL 32214-3647

Phone

(904) 542-9703

Fax

(904) 542-9483

NPI assigned

Apr 27, 2006

Last updated

Feb 6, 2025By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Doctor of Osteopathy

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Badia Medical, LLC

  dba Lifeguard Pediatrics

  • Pediatrics Physician
  • Warner Robins, GA
  • NPI 1679584601
  NPD (past)
• Cornerstone Medical Assoc., LLC

  • Pediatrics Physician
  • Perry, GA
  • NPI 1275575888
  NPD (past)
• Personal Recovery Network LLC

  dba LifeStance Health

  • Psychiatry Physician
  • Stockbridge, GA
  • NPI 1881990869
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1146096000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1738800000000",
    "number": "1760449383",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2080 CHILD ST",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322143600",
            "telephone_number": "904-542-9703",
            "fax_number": "904-542-9483"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2080 CHILD ST",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322143647",
            "telephone_number": "904-542-9703",
            "fax_number": "904-542-9483"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "NIEBAUM",
        "first_name": "KEVIN",
        "middle_name": "K.",
        "credential": "D.O.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-04-27",
        "last_updated": "2025-02-06",
        "certification_date": "2025-02-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "GA",
            "license": "047353",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000834809D",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Nicole M Sweet-McIntire LLC
• Ernst Nicolitz, M.D
• Francesca Nicoloso, PA
• Nidal S Elias DDS PA
• Nidra LLC
• Claudia Nieblas Morfa
• Jordyn Paige Niederhiser, M.S., BCBA
• Brandon Nielsen, DO
• Heather D Nielsen, DO
• Tashera Muray Nielsen

• Pediatrics Physician in Jacksonville, FL
• Providers in Jacksonville, FL by specialty
• Pediatrics Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 6, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.