Provider Demographics
NPI:1710969894
Name:COOK, HEATHER R (OD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:R
Last Name:COOK
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:PO BOX 22009
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97269-2009
Mailing Address - Country:US
Mailing Address - Phone:503-558-7372
Mailing Address - Fax:503-344-5140
Practice Address - Street 1:1955 NW NORTHRUP ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1614
Practice Address - Country:US
Practice Address - Phone:503-227-2020
Practice Address - Fax:503-222-0614
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2628AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150612Medicaid
U66928Medicare UPIN
OR100428Medicare PIN