Individual
MR. BRIAN DOUGLASS BOURBON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CERTIFIED PEDORTHIST
Contact information
Practice address
11709 OLD BALLAS RD, SUITE 201, CREVE COEUR, MO 63141-7029
(314) 432-1903
(314) 432-5105
Mailing address
PO BOX 419074, CREVE COEUR, MO 63141-9074
(314) 432-1903
(314) 432-5105
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
CPED3999
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CPED3999
CERTIFIED PEDORTHIST
MO
Enumeration date
06/20/2013
Last updated
06/20/2013
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