Provider Demographics
NPI:1497828842
Name:HEATHER M BERGERUD OD INC
Entity Type:Organization
Organization Name:HEATHER M BERGERUD OD INC
Other - Org Name:HEATHER M BERGERUD OD
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BERGERUD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:952-403-1694
Mailing Address - Street 1:290 GREENLEAF CT.
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317
Mailing Address - Country:US
Mailing Address - Phone:952-403-1694
Mailing Address - Fax:
Practice Address - Street 1:3745 LOUISIANA AVE S
Practice Address - Street 2:
Practice Address - City:ST. LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426
Practice Address - Country:US
Practice Address - Phone:952-922-4427
Practice Address - Fax:952-922-4761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2621152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2201839OtherMEDICA
MN300J5BEOtherBCBS
MNU72740Medicare UPIN