Provider Demographics
NPI:1336272285
Name:BYERGO, BRADLEY ALAN (OD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALAN
Last Name:BYERGO
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 1:1384 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2444
Mailing Address - Country:US
Mailing Address - Phone:636-946-9242
Mailing Address - Fax:636-946-4903
Practice Address - Street 1:1384 S 5TH ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2444
Practice Address - Country:US
Practice Address - Phone:636-946-9242
Practice Address - Fax:636-946-4903
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002015240152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO315859009Medicaid