Healthcare Provider Details

I. General information

NPI: 1619027703
Provider Name (Legal Business Name): KYLE E BROST O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

352 S BROADVIEW ST
CAPE GIRARDEAU MO
63703
US

IV. Provider business mailing address

352 S BROADVIEW ST
CAPE GIRARDEAU MO
63703-5703
US

V. Phone/Fax

Practice location:
  • Phone: 573-334-8595
  • Fax: 573-334-4143
Mailing address:
  • Phone: 573-334-8595
  • Fax: 573-334-4143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberT02741
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberT02741
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberT02741
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License NumberT02741
License Number StateMO
# 5
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02741
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: