1508363664 NPI number — DAVID M ERICKSON MD

Table of content: DAVID M ERICKSON MD (NPI 1508363664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508363664 NPI number — DAVID M ERICKSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERICKSON
Provider First Name:
DAVID
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1508363664
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3671 SOUTHWESTERN BLVD
Provider Second Line Business Mailing Address:
ST 101
Provider Business Mailing Address City Name:
ORCHARD PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14127-1749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-662-7008
Provider Business Mailing Address Fax Number:
716-662-5226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3671 SOUTHWESTERN BLVD
Provider Second Line Business Practice Location Address:
ST 101
Provider Business Practice Location Address City Name:
ORCHARD PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14127-1749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-662-7008
Provider Business Practice Location Address Fax Number:
716-662-5226
Provider Enumeration Date:
04/06/2018

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 318722 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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