Provider Demographics
NPI:1407899479
Name:ERICKSON, JOEL S (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:S
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 1:500 DOYLE PARK DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4558
Mailing Address - Country:US
Mailing Address - Phone:707-527-8444
Mailing Address - Fax:707-578-7863
Practice Address - Street 1:500 DOYLE PARK DR
Practice Address - Street 2:SUITE 205
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4558
Practice Address - Country:US
Practice Address - Phone:707-527-8444
Practice Address - Fax:707-578-7863
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG54218207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G542180Medicaid
CA00G542180Medicaid
CA00G542180Medicare ID - Type UnspecifiedPPIN