Brian Douglass Bourbon, CERTIFIED PEDORTHIST

Primary specialty

SpecialistTaxonomy code 174400000X

License

CPED3999 Issued in MO

Practice address

11709 Old Ballas Rd
Suite 201
Creve Coeur, MO 63141-7029

Phone

(314) 432-1903

Fax

(314) 432-5105

NPI assigned

Jun 20, 2013

Last updated

Jun 20, 2013By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1371686400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1371686400000",
    "number": "1790124923",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 419074",
            "city": "CREVE COEUR",
            "state": "MO",
            "postal_code": "631419074",
            "telephone_number": "314-432-1903",
            "fax_number": "314-432-5105"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11709 OLD BALLAS RD",
            "address_2": "SUITE 201",
            "city": "CREVE COEUR",
            "state": "MO",
            "postal_code": "631417029",
            "telephone_number": "314-432-1903",
            "fax_number": "314-432-5105"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BOURBON",
        "first_name": "BRIAN",
        "middle_name": "DOUGLASS",
        "name_prefix": "Mr.",
        "credential": "CERTIFIED PEDORTHIST",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2013-06-20",
        "last_updated": "2013-06-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "MO",
            "license": "CPED3999",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CERTIFIED PEDORTHIST",
            "identifier": "CPED3999",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Jaclyn Bolzenius, M. A.
• Kaitlyn Borden, OTR/L
• Bradley Elliott Borello, OD
• Abby Christine Boron, SLP
• Ramona Georgeta Bosma, D.M.D.
• Tonya K Bourn, O.D.
• Loren Nicole Boushey, COTA/L
• Nancy Claire Bradley, R.D., L.D., C.D.E.
• Gregory H Branham, MD
• Kent D Branson, M.D.

• Specialist in Creve Coeur, MO
• Providers in Creve Coeur, MO by specialty
• Specialist in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 20, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.