Provider Demographics
NPI:1851340152
Name:BOURN, TONYA K (OD)
Entity Type:Individual
Prefix:DR
First Name:TONYA
Middle Name:K
Last Name:BOURN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12101 WOODCREST EXECUTIVE DR STE 150
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5050
Mailing Address - Country:US
Mailing Address - Phone:314-921-2020
Mailing Address - Fax:314-863-9977
Practice Address - Street 1:12101 WOODCREST EXECUTIVE DR STE 150
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-5050
Practice Address - Country:US
Practice Address - Phone:314-863-9966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008999152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008999Medicaid
U67104Medicare UPIN