Provider Demographics
NPI:1619027703
Name:BROST, KYLE E (OD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:E
Last Name:BROST
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 1:352 S BROADVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5703
Mailing Address - Country:US
Mailing Address - Phone:573-334-8595
Mailing Address - Fax:573-334-4143
Practice Address - Street 1:352 S BROADVIEW ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703
Practice Address - Country:US
Practice Address - Phone:573-334-8595
Practice Address - Fax:573-334-4143
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02741152WC0802X, 152WL0500X, 152WP0200X, 152WX0102X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO312628134Medicaid
MO105650OtherBLUE SHIELD PROVIDER #
MO410037380Medicare ID - Type UnspecifiedMEDICARE RAILROAD NUMBER
MO0242210001Medicare NSC
MO001009203Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
MO312628134Medicaid
MO0242210002Medicare NSC
MOT42800Medicare UPIN
MO001009205Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER