Provider Demographics
NPI:1083714364
Name:ERICKSON, LIA SIMPSON (MD)
Entity Type:Individual
Prefix:
First Name:LIA
Middle Name:SIMPSON
Last Name:ERICKSON
Suffix:
Gender:F
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:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-718-4360
Mailing Address - Fax:336-718-4369
Practice Address - Street 1:648 EAST MONMOUTH STREET
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107
Practice Address - Country:US
Practice Address - Phone:336-718-4630
Practice Address - Fax:336-718-4369
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200601245208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905225Medicaid
TL-850OtherCO TRAINING LICENSE