Provider Demographics
NPI:1457460255
Name:ERICKSON, DINA H (OD)
Entity Type:Individual
Prefix:DR
First Name:DINA
Middle Name:H
Last Name:ERICKSON
Suffix:
Gender:F
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:PACIFIC UNIVERSITY COLLEGE OF OPTOMETRY
Mailing Address - Street 2:2043 COLLEGE WAY
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116
Mailing Address - Country:US
Mailing Address - Phone:503-352-3007
Mailing Address - Fax:503-352-2929
Practice Address - Street 1:PACIFIC UNIVERSITY COLLEGE OF OPTOMETRY
Practice Address - Street 2:2043 COLLEGE WAY
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116
Practice Address - Country:US
Practice Address - Phone:503-352-3007
Practice Address - Fax:503-352-2929
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4000ATI152W00000X
CA10327T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR208312Medicaid
ORU80104Medicare ID - Type Unspecified