Provider Demographics
NPI:1811990633
Name:BRUDNER, PETER N (OD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:N
Last Name:BRUDNER
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 1:910 E STOWELL RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-7001
Mailing Address - Country:US
Mailing Address - Phone:805-925-2637
Mailing Address - Fax:805-347-0033
Practice Address - Street 1:425 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-2805
Practice Address - Country:US
Practice Address - Phone:805-736-2020
Practice Address - Fax:805-737-1733
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7924T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1312330002OtherMEDICARE DMERC
CASD0079240Medicaid
CA1312330002OtherMEDICARE DMERC
CASD0079240Medicaid