| Doctor Name: | MR. BRIAN DOUGLASS BOURBON |
| NPI Number: | 1790124923 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | CERTIFIED PEDORTHIST |
| License Number: | CPED3999 |
| Business Practice Address: | 11709 Old Ballas Rd Suite 201 Creve Coeur, MO - 631417029 |
| Business Phone Number: | 3144321903 |
| Business Fax Number: | 3144325105 |
| Mailing Address: | Po Box 419074, CREVE COEUR |
| State: | MO |
| Postal Code: | 631419074 |
| Phone Number: | 3144321903 |
| Fax Number: | 3144325105 |
| NPI Enumeration Date: | 06/20/2013 |
| NPI Last Update Date: | 06/20/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 174400000X |
| License Number: | CPED3999 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MO |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Specialist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |