Provider Demographics
NPI:1154060762
Name:ERICKSON, SAMUEL GLEN (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:GLEN
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 STANTON L YOUNG BLVD
Mailing Address - Street 2:AAT 1464
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5018
Mailing Address - Country:US
Mailing Address - Phone:405-271-5504
Mailing Address - Fax:
Practice Address - Street 1:800 STANTON L YOUNG BLVD
Practice Address - Street 2:AAT 1464
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5018
Practice Address - Country:US
Practice Address - Phone:405-271-5504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK39489207YX0007X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck