1427241843 NPI number — PAUL C BRUDERER O D P C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427241843 NPI number — PAUL C BRUDERER O D P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAUL C BRUDERER O D P C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WEST VALLEY VISION SOURCE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427241843
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2782 S 5600 W STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST VALLEY CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84120-5592
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-969-9999
Provider Business Mailing Address Fax Number:
801-746-1007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2782 S 5600 W STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST VALLEY CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84120-5592
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-969-9999
Provider Business Practice Location Address Fax Number:
801-746-1007
Provider Enumeration Date:
08/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRUDERER
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
CHRISTIAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
801-969-9999

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  4942085-9934 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7664549 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2157848 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 528558921001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 81648 . This is a "PEHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: IDX5199969 . This is a "UNIVERSITY HEALTH CARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: TPRA08151 . This is a "MOLINA HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 49420859901 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 291777 . This is a "ALTIUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5510561 . This is a "CCN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 788511 . This is a "DESERET MUTUAL" identifier . This identifiers is of the category "OTHER".




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