1821079310 NPI number — MR. JOHN ERICKSON M.D.

Table of content: MR. JOHN ERICKSON M.D. (NPI 1821079310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821079310 NPI number — MR. JOHN ERICKSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERICKSON
Provider First Name:
JOHN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821079310
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 28949
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93729-8949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-228-4200
Provider Business Mailing Address Fax Number:
559-224-3920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 W HERNDON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93612-0204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-324-6200
Provider Business Practice Location Address Fax Number:
559-324-6280
Provider Enumeration Date:
11/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  G55499 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G554990 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00G554990 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 110125074 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 77040368493612B011 . This is a "CHAMPUS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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