Provider Demographics
NPI:1316956576
Name:BRUDERER, PAUL CHRISTIAN (OD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:CHRISTIAN
Last Name:BRUDERER
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 1:2782 S 5600 W STE 101
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-5592
Mailing Address - Country:US
Mailing Address - Phone:801-969-9999
Mailing Address - Fax:801-746-1007
Practice Address - Street 1:2782 S 5600 W STE 101
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-5592
Practice Address - Country:US
Practice Address - Phone:801-969-9999
Practice Address - Fax:801-746-1007
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4942085-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU93372Medicare UPIN
UT005713801Medicare ID - Type Unspecified