Provider Demographics
NPI:1336702224
Name:NIEBOER, MICAH JON (MD)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:JON
Last Name:NIEBOER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 E FOWLER AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-2305
Mailing Address - Country:US
Mailing Address - Phone:813-978-9700
Mailing Address - Fax:
Practice Address - Street 1:5901 E FOWLER AVE STE 100
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-2305
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30229207X00000X
MN68395207X00000X
FLME168209207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery