Provider Demographics
NPI:1821602756
Name:DUBERRY, COURTNEY KAY (OD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:KAY
Last Name:DUBERRY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:KAY
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:12805 TOWN AND FOUR DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6222
Mailing Address - Country:US
Mailing Address - Phone:763-438-6192
Mailing Address - Fax:
Practice Address - Street 1:915 N GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1621
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020018357152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist