=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710614219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLAUDIA HERAIZ OD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2022
-----------------------------------------------------
Last Update Date | 11/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19576 HOLT ST NW
-----------------------------------------------------
City | ELK RIVER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55330-1287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-241-2083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 253 LAKE ST E APT 305
-----------------------------------------------------
City | WAYZATA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55391-1667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-760-9618
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901005762
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3810
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3983-35
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------