MEDICARE: DR. TONYA K BOURN O.D.

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	046008999	IL
2	152W00000X	Optometrist	2019047752	MO

General Provider Information

NPI Number	:	1851340152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TONYA K BOURN O.D.

Provider Business Mailing Address
First Line	:	12101 WOODCREST EXECUTIVE DR STE 150
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-5050
Country	:	US
Telephone Number	:	314-391-9400
Fax Number	:	618-861-6003

Provider Business Practice Location Address
First Line	:	12101 WOODCREST EXECUTIVE DR STE 150
Second Line	:
City	:	CREVE COEUR
State	:	MO
Zip	:	63141-5050
Country	:	US
Telephone Number	:	314-863-9966
Fax Number	:

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

Provider Enumeration Date	:	05/06/2006
Last Update Date	:	12/11/2025

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