Provider Demographics
NPI:1134166713
Name:AUGUSTIN-GAUDIOSO, HEATHER M (OD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:M
Last Name:AUGUSTIN-GAUDIOSO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MRS
Other - First Name:HEATHER
Other - Middle Name:AUGUSTIN
Other - Last Name:GAUDIOSO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:9001 UNBRIDLE LN
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6774
Mailing Address - Country:US
Mailing Address - Phone:631-974-0750
Mailing Address - Fax:
Practice Address - Street 1:805 LANCASTER BYP W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-4773
Practice Address - Country:US
Practice Address - Phone:803-357-7700
Practice Address - Fax:803-227-8996
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006911152W00000X
SC2099152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC425E1Medicare ID - Type Unspecified
V07405Medicare UPIN