Provider Demographics
NPI:1093707556
Name:ERICKSON, MICHAEL DENNIS (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DENNIS
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4538 KLAHANIE DR SE
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029
Mailing Address - Country:US
Mailing Address - Phone:425-392-9982
Mailing Address - Fax:815-301-5473
Practice Address - Street 1:4538 KLAHANIE DR SE
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029
Practice Address - Country:US
Practice Address - Phone:425-392-9982
Practice Address - Fax:815-301-5473
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003260152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU62791Medicare UPIN
WA8808683Medicare ID - Type Unspecified