Provider Demographics
NPI:1568460723
Name:BRUSATTI, ROBERT CHRISTIAN (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CHRISTIAN
Last Name:BRUSATTI
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 1:12990 MANCHESTER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1860
Mailing Address - Country:US
Mailing Address - Phone:314-966-5000
Mailing Address - Fax:314-909-6666
Practice Address - Street 1:12990 MANCHESTER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1860
Practice Address - Country:US
Practice Address - Phone:314-966-5000
Practice Address - Fax:314-909-6666
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03150152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1293001OtherPTAN
U51025Medicare UPIN
MOMA1293001OtherPTAN