Provider Demographics
NPI:1265458749
Name:ERICSON, KEVIN R (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:ERICSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:611 E DOUGLAS RD
Mailing Address - Street 2:STE 407
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-1464
Mailing Address - Country:US
Mailing Address - Phone:574-335-6500
Mailing Address - Fax:574-335-0772
Practice Address - Street 1:611 E DOUGLAS RD
Practice Address - Street 2:STE 407
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1464
Practice Address - Country:US
Practice Address - Phone:574-335-6500
Practice Address - Fax:574-335-0772
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01046492207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200142060AOtherMEDICAID
E12532Medicare UPIN