Provider Demographics
NPI:1033369244
Name:BURCH, BRENT D (OD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:D
Last Name:BURCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10529 HOSLER RD STE A
Mailing Address - Street 2:
Mailing Address - City:LEO
Mailing Address - State:IN
Mailing Address - Zip Code:46765-9736
Mailing Address - Country:US
Mailing Address - Phone:260-627-2669
Mailing Address - Fax:260-627-2011
Practice Address - Street 1:7625 SOUTHTOWN XING
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46816-2517
Practice Address - Country:US
Practice Address - Phone:260-447-9731
Practice Address - Fax:260-441-8276
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2358152W00000X
IN18002685A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU61224Medicare UPIN