Basic Information
| Provider Information | |||||||||
| NPI: | 1649314055 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERICSON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10470 OLD PLACERVILLE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958272539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2800 L ST | ||||||||
| Address2: | 6TH FLOOR | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168874040 | ||||||||
| FaxNumber: | 9168874045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2007 | ||||||||
| LastUpdateDate: | 05/26/2015 | ||||||||
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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 | 207RC0000X | A111124 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | DK902Z | 01 | CA | PTAN | OTHER |