Provider Demographics
NPI:1003806233
Name:SWIDERSKI, BRENDA J (OD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:SWIDERSKI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:J
Other - Last Name:ANDERSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:8080 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2104
Mailing Address - Country:US
Mailing Address - Phone:619-589-7500
Mailing Address - Fax:619-589-7500
Practice Address - Street 1:6945 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-1754
Practice Address - Country:US
Practice Address - Phone:619-697-4600
Practice Address - Fax:619-464-5526
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT12109152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0052930Medicaid
CAGR0052930Medicaid