Provider Demographics
NPI:1376612309
Name:FOUTCH, BRIAN KEITH (OD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEITH
Last Name:FOUTCH
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 1:101 BARNETT DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2401
Mailing Address - Country:US
Mailing Address - Phone:618-581-9392
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY BLVD
Practice Address - Street 2:331 MARILLAC HALL, UMSL COLLEGE OF OPTOMETRY
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-4400
Practice Address - Country:US
Practice Address - Phone:314-516-5499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5978T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist