1023122017 NPI number — BRANDON DOUGLAS ROUSE OD

Table of content: BRANDON DOUGLAS ROUSE OD (NPI 1023122017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023122017 NPI number — BRANDON DOUGLAS ROUSE OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROUSE
Provider First Name:
BRANDON
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROUSE
Provider Other First Name:
BRANDON
Provider Other Middle Name:
DOUGLAS
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1023122017
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 807
Provider Second Line Business Mailing Address:
1301 COOK ST
Provider Business Mailing Address City Name:
KENNETT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-888-2884
Provider Business Mailing Address Fax Number:
575-888-3799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 COOK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNETT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63857-3259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-888-2884
Provider Business Practice Location Address Fax Number:
575-888-3799
Provider Enumeration Date:
08/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  T03483 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 314803701 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".