Provider Demographics
NPI:1417098690
Name:ERICSON, DAVID LAMONT (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LAMONT
Last Name:ERICSON
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 1:1162 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-1438
Mailing Address - Country:US
Mailing Address - Phone:847-367-2400
Mailing Address - Fax:
Practice Address - Street 1:1162 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-1438
Practice Address - Country:US
Practice Address - Phone:847-367-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117087207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL820800OtherMEDICARE PTAN(GROUP)
ILK36911OtherMEDICARE PTAN (INDIVIDUAL)