Provider Demographics
NPI:1528019080
Name:ERICKSON, NEIL (OD)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:
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 1:1280 W LANTANA RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LANTANA
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1543
Mailing Address - Country:US
Mailing Address - Phone:561-582-3383
Mailing Address - Fax:561-582-8821
Practice Address - Street 1:1280 W LANTANA RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-1543
Practice Address - Country:US
Practice Address - Phone:561-582-3383
Practice Address - Fax:561-582-8821
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL675152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL410010722OtherRAILROAD MEDICARE
FL084131500Medicaid
FL084131500Medicaid
FL0568170001Medicare NSC
FL410010722Medicare PIN
FL19335ZMedicare PIN