Basic Information
| Provider Information | |||||||||
| NPI: | 1619027703 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROST | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 352 S BROADVIEW ST | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637035703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733348595 | ||||||||
| FaxNumber: | 5733344143 | ||||||||
| Practice Location | |||||||||
| Address1: | 352 S BROADVIEW ST | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733348595 | ||||||||
| FaxNumber: | 5733344143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 07/30/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | T02741 | MO | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152WL0500X | T02741 | MO | N | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation | 152WP0200X | T02741 | MO | N | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WX0102X | T02741 | MO | N | Eye and Vision Services Providers | Optometrist | Occupational Vision | 152W00000X | T02741 | MO | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 312628134 | 05 | MO | MEDICAID | 105650 | 01 | MO | BLUE SHIELD PROVIDER # | OTHER |