Provider Demographics
NPI:1265642508
Name:ERICKSON, MATHEW C (MD)
Entity Type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:C
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2780
Mailing Address - Street 2:
Mailing Address - City:JENA
Mailing Address - State:LA
Mailing Address - Zip Code:71342-2780
Mailing Address - Country:US
Mailing Address - Phone:318-992-9200
Mailing Address - Fax:318-992-9280
Practice Address - Street 1:302-A BUSHLEY STREET
Practice Address - Street 2:ERICKSON FAMILY MEDICINE
Practice Address - City:HARRISONBURG
Practice Address - State:LA
Practice Address - Zip Code:71340-0302
Practice Address - Country:US
Practice Address - Phone:318-744-5504
Practice Address - Fax:318-744-5505
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.201826207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1078085Medicaid
LA09216Medicaid