Provider Demographics
NPI:1114272200
Name:BURTON, GABRIEL THIERRY (OD)
Entity Type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:THIERRY
Last Name:BURTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-454-6026
Mailing Address - Fax:314-454-2368
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:STE 3110
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6026
Practice Address - Fax:314-454-2368
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012024705152WP0200X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO319876504Medicaid
780126OtherANTHEM
MO140330004Medicare PIN
142780004Medicare PIN