Provider Demographics
NPI:1427241843
Name:PAUL C BRUDERER O D P C
Entity type:Organization
Organization Name:PAUL C BRUDERER O D P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:BRUDERER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-969-9999
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4942085-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7664549OtherAETNA
2157848OtherFIRST HEALTH
UT528558921001Medicaid
81648OtherPEHP
UTIDX5199969OtherUNIVERSITY HEALTH CARE
UTTPRA08151OtherMOLINA HEALTHCARE
49420859901OtherBLUE CROSS BLUE SHIELD
291777OtherALTIUS
5510561OtherCCN
788511OtherDESERET MUTUAL
=========OtherUNITED HEALTH CARE
788511OtherDESERET MUTUAL
=========OtherTALL TREE ADMINISTRATORS
5510561OtherCCN