Provider Demographics
NPI:1164477931
Name:ERIKSON, BRAD C (DO)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:C
Last Name:ERIKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:BRAD C ERIKSON FAMILY PRACTICE
Mailing Address - Street 2:2375 E. SUNNYSIDE RD, STE J
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-542-7060
Mailing Address - Fax:208-522-2202
Practice Address - Street 1:2375 E. SUNNYSIDE RD, STE J
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-542-7060
Practice Address - Fax:208-522-2202
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-270207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806190400Medicaid
ID806190400Medicaid
ID1302455Medicare PIN