Provider Demographics
NPI:1083893192
Name:KOONS, BRETT D (OD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:D
Last Name:KOONS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1314
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-1314
Mailing Address - Country:US
Mailing Address - Phone:573-346-7899
Mailing Address - Fax:573-346-7744
Practice Address - Street 1:323 E HIGHWAY 54
Practice Address - Street 2:SUITE 104
Practice Address - City:CAMDENTON
Practice Address - State:MO
Practice Address - Zip Code:65020-9599
Practice Address - Country:US
Practice Address - Phone:573-346-7899
Practice Address - Fax:573-346-7744
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007031193152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2007031193OtherSTATE LICENSE