Provider Demographics
NPI:1245228592
Name:KURTZ, BRIAN EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:EDWARD
Last Name:KURTZ
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 207243
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7243
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:820 E LEE ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2011
Practice Address - Country:US
Practice Address - Phone:334-393-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT-001821152W00000X
ALR133TA477152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I416960Medicare PIN
GAU30660Medicare UPIN
GA410006834OtherRAILROAD MEDICARE GROUP #
GA581245844OtherVISION CARE PLAN
GA581245844OtherBLUE CROSS BLUE SHIELD GA
GA41ZCDSGMedicare ID - Type Unspecified
GA0430710001Medicare NSC
GA581245844OtherPARAGON
GA410044025OtherRAILROAD MEDICARE
GA581245844OtherTRICARE
GA00810103DMedicaid
GA17015OtherAVESIS
GAGRP991Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
GA581245844OtherVISION SERVICE PLAN
GA581245844OtherSOUTHLAND