Provider Demographics
NPI:1063484376
Name:ERICKSON, CLINTON (MD)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6838 WOODLAKE DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-1141
Mailing Address - Country:US
Mailing Address - Phone:419-843-8907
Mailing Address - Fax:
Practice Address - Street 1:950 W WOOSTER ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2603
Practice Address - Country:US
Practice Address - Phone:419-354-9810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.084841207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2595222Medicaid
OH2595222Medicaid
OHI32132Medicare UPIN
P00281363Medicare PIN