Basic Information
| Provider Information | |||||||||
| NPI: | 1457642282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICKSTAD | ||||||||
| FirstName: | LANDON | ||||||||
| MiddleName: | TAYLOR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847176 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032371800 | ||||||||
| FaxNumber: | 9032371810 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 MEDICAL DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756055205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037577871 | ||||||||
| FaxNumber: | 9037532479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2011 | ||||||||
| LastUpdateDate: | 08/25/2016 | ||||||||
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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 | 208800000X | Q8053 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.