Provider Demographics
NPI:1588667992
Name:SUMNER, BRIAN PATRICK (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:PATRICK
Last Name:SUMNER
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 1:320 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-3218
Mailing Address - Country:US
Mailing Address - Phone:636-239-2179
Mailing Address - Fax:636-239-9592
Practice Address - Street 1:320 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-3218
Practice Address - Country:US
Practice Address - Phone:636-239-2179
Practice Address - Fax:636-239-9592
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2351152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2202100OtherUNITED HEALTH CARE
MO233006OtherGROUP HEALTH PLAN
MO122489OtherHEALTHLINK
MO310206214Medicaid
MO32218OtherBLUE CROSS BLUE SHIELD
MO310206214Medicaid
MO000009375Medicare ID - Type Unspecified