Provider Demographics
NPI:1851457030
Name:BOURDEAU, HEATHER ANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:ANNE
Last Name:BOURDEAU
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 1:587 HARTFORD AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-8031
Mailing Address - Country:US
Mailing Address - Phone:802-295-4887
Mailing Address - Fax:
Practice Address - Street 1:587 HARTFORD AVE
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-8031
Practice Address - Country:US
Practice Address - Phone:802-295-4887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4373-TP152WL0500X, 152WP0200X, 152W00000X
VT030.0133973152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA7940836OtherAETNA
MA0323501Medicaid
MAAA85035OtherHARVARD PILGRIM
MAW16497OtherBC/BS
MAAA85035OtherHARVARD PILGRIM
MAW16497OtherBC/BS