Provider Demographics
NPI:1023122017
Name:ROUSE, BRANDON DOUGLAS (OD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:DOUGLAS
Last Name:ROUSE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:BRANDON
Other - Middle Name:DOUGLAS
Other - Last Name:ROUSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 807
Mailing Address - Street 2:1301 COOK ST
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857
Mailing Address - Country:US
Mailing Address - Phone:573-888-2884
Mailing Address - Fax:575-888-3799
Practice Address - Street 1:1301 COOK ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3259
Practice Address - Country:US
Practice Address - Phone:573-888-2884
Practice Address - Fax:575-888-3799
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03483152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO314803701Medicaid
MO314803701Medicaid
U76384Medicare UPIN