Basic Information
| Provider Information | |||||||||
| NPI: | 1114028180 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ERICKSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3360 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253170279 | ||||||||
| FaxNumber: | 4253170291 | ||||||||
| Practice Location | |||||||||
| Address1: | 12800 BOTHELL EVERETT HWY | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982086642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253165150 | ||||||||
| FaxNumber: | 4253165153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 01/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00018476 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1678705 | 05 | WA | MEDICAID |