Provider Demographics
NPI:1053458745
Name:HAEGERSTROM-PORTNOY, GUNILLA (OD, PHD)
Entity Type:Individual
Prefix:
First Name:GUNILLA
Middle Name:
Last Name:HAEGERSTROM-PORTNOY
Suffix:
Gender:F
Credentials:OD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SCHOOL OF OPTOMETRY UNIVERSITY OF CALIFORNIA
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94720-2020
Mailing Address - Country:US
Mailing Address - Phone:510-642-9966
Mailing Address - Fax:
Practice Address - Street 1:SCHOOL OF OPTOMETRY UNIVERSITY OF CALIFORNIA
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-2020
Practice Address - Country:US
Practice Address - Phone:510-642-9966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5682152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist