Provider Demographics
NPI:1265487961
Name:ERICKSON, LARRY R (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:R
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2600 LAKE LUCIEN DR
Mailing Address - Street 2:SUITE 180
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7233
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-875-0518
Practice Address - Street 1:13855 US HIGHWAY 1
Practice Address - Street 2:SUITE 4
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3232
Practice Address - Country:US
Practice Address - Phone:772-646-6100
Practice Address - Fax:772-646-6110
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2009-12-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME98052207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46494VMedicare PIN
D22861Medicare UPIN