Provider Demographics
NPI:1558425389
Name:NORMAN, BRIAN K (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:K
Last Name:NORMAN
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 1:21 DOCTORS PARK
Mailing Address - Street 2:SUITE B
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4927
Mailing Address - Country:US
Mailing Address - Phone:573-803-2211
Mailing Address - Fax:
Practice Address - Street 1:21 DOCTORS PARK
Practice Address - Street 2:SUITE B
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4927
Practice Address - Country:US
Practice Address - Phone:573-803-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03491152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT03491OtherMISSOURI OPTOMETRY LICENSE
MOT03491OtherMISSOURI OPTOMETRY LICENSE
MO000091193Medicare ID - Type Unspecified