Provider Demographics
NPI:1669511200
Name:ERICKSON, HEATHER J (OD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:J
Last Name:ERICKSON
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 1:3719 E MERIDIAN LOOP
Mailing Address - Street 2:STE. C
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7270
Mailing Address - Country:US
Mailing Address - Phone:907-357-9595
Mailing Address - Fax:907-357-9575
Practice Address - Street 1:3719 E MERIDIAN LOOP
Practice Address - Street 2:STE. C
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7270
Practice Address - Country:US
Practice Address - Phone:907-357-9595
Practice Address - Fax:907-357-9575
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK197152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOD78741Medicaid