Provider Demographics
NPI:1669545018
Name:BERGERUD, HEATHER MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:MARIE
Last Name:BERGERUD
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 1:290 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
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2621152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2201839OtherMEDICA
MN300J5BEOtherBCBS
MN2201839OtherMEDICA