MEDICARE: BRENT D. BURCH OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2358	CO
2	152W00000X	Optometrist	18002685A	IN

General Provider Information

NPI Number	:	1033369244
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT D. BURCH OD

Provider Business Mailing Address
First Line	:	10529 HOSLER RD STE A
Second Line	:
City	:	LEO
State	:	IN
Zip	:	46765-9736
Country	:	US
Telephone Number	:	260-627-2669
Fax Number	:	260-627-2011

Provider Business Practice Location Address
First Line	:	7625 SOUTHTOWN XING
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46816-2517
Country	:	US
Telephone Number	:	260-447-9731
Fax Number	:	260-441-8276

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2008
Last Update Date	:	12/10/2012

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