Basic Information
| Provider Information | |||||||||
| NPI: | 1669493102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIDERMAN | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10077 SOUTH FEDERAL HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723983244 | ||||||||
| FaxNumber: | 7723988090 | ||||||||
| Practice Location | |||||||||
| Address1: | 10077 SOUTH FEDERAL HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349524778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723983244 | ||||||||
| FaxNumber: | 7723988090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 12/30/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC1718 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 19949 | 01 | FL | BC/BS | OTHER | 410049282 | 01 | FL | RAILROAD | OTHER | 620802900 | 05 | FL | MEDICAID |