Provider Demographics
NPI:1932154341
Name:OFFERDAHL, BRENDA LYNN (OD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LYNN
Last Name:OFFERDAHL
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 1:2120 THAIN GRADE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4105
Mailing Address - Country:US
Mailing Address - Phone:208-746-1050
Mailing Address - Fax:
Practice Address - Street 1:2120 THAIN GRADE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4105
Practice Address - Country:US
Practice Address - Phone:208-746-1050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP968152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist