Provider Demographics
NPI:1447409974
Name:LIFFLAND, BRENDA R (OD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:R
Last Name:LIFFLAND
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 9TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1224
Mailing Address - Country:US
Mailing Address - Phone:727-895-2020
Mailing Address - Fax:727-823-8796
Practice Address - Street 1:2650 TAMPA RD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3144
Practice Address - Country:US
Practice Address - Phone:727-785-4419
Practice Address - Fax:727-789-3351
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4340152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000415700Medicaid
FL000415700Medicaid