Provider Demographics
NPI:1033396791
Name:ERICKSON, JOSEPH R (RDO)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:R
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:RDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 PALACE GARDENS RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01607-1725
Mailing Address - Country:US
Mailing Address - Phone:508-365-8771
Mailing Address - Fax:
Practice Address - Street 1:12 PALACE GARDENS RD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01607-1725
Practice Address - Country:US
Practice Address - Phone:508-365-8771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4453156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0715794Medicaid