Provider Demographics
NPI:1316047095
Name:BERHOW, NICOLE LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LYNN
Last Name:BERHOW
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 1:600 E NORTHERN LIGHTS BLVD
Mailing Address - Street 2:#136
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-4132
Mailing Address - Country:US
Mailing Address - Phone:907-258-6333
Mailing Address - Fax:
Practice Address - Street 1:600 E NORTHERN LIGHTS BLVD
Practice Address - Street 2:#136
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-4132
Practice Address - Country:US
Practice Address - Phone:907-258-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK0178152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOD1178Medicaid
AKK150265Medicare ID - Type UnspecifiedPROVIDER #