Provider Demographics
NPI:1457642282
Name:ERICKSTAD, LANDON TAYLOR (MD)
Entity Type:Individual
Prefix:
First Name:LANDON
Middle Name:TAYLOR
Last Name:ERICKSTAD
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 847176
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7176
Mailing Address - Country:US
Mailing Address - Phone:903-237-1800
Mailing Address - Fax:903-237-1810
Practice Address - Street 1:802 MEDICAL DR STE 400
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5205
Practice Address - Country:US
Practice Address - Phone:903-757-7871
Practice Address - Fax:903-753-2479
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ8053208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX519472YKS4Medicare PIN