Provider Demographics
NPI:1285673095
Name:ERICKSON, ROBERT LEIF (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEIF
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:OD
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 311
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:VT
Mailing Address - Zip Code:05161-0311
Mailing Address - Country:US
Mailing Address - Phone:802-824-3695
Mailing Address - Fax:
Practice Address - Street 1:44 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-5031
Practice Address - Country:US
Practice Address - Phone:802-775-0862
Practice Address - Fax:802-747-7714
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030-0000275152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTVN2087Medicare PIN
VTU76671Medicare UPIN