Provider Demographics
NPI:1205863123
Name:ERICKSON, MARK A (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 STARLIGHT DR
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4513
Mailing Address - Country:US
Mailing Address - Phone:320-828-2701
Mailing Address - Fax:
Practice Address - Street 1:251 COUNTY ROAD 120
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4872
Practice Address - Country:US
Practice Address - Phone:320-202-8949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47324207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine