Provider Demographics
NPI:1619944543
Name:GULLICKSON-COWDEN, HEATHER N (OD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:N
Last Name:GULLICKSON-COWDEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:HEATHER
Other - Middle Name:N
Other - Last Name:COWDEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:715-838-5222
Mailing Address - Fax:
Practice Address - Street 1:2409 STOUT RD
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2757
Practice Address - Country:US
Practice Address - Phone:715-231-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND545152W00000X
MN2581152W00000X
WI3015-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38643000Medicaid
12698OtherND MEDICAL ASSISTANCE
638218500OtherMN MEDICAL ASSISTANCE
U63499Medicare UPIN
WI38643000Medicaid