Provider Demographics
NPI:1629139647
Name:ERICKSON, CANDACE JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CANDACE
Middle Name:JEAN
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:315 W 86 ST
Mailing Address - Street 2:#14B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-3177
Mailing Address - Country:US
Mailing Address - Phone:212-362-2260
Mailing Address - Fax:212-362-2260
Practice Address - Street 1:5 W 86TH ST
Practice Address - Street 2:SUITE 9C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-3603
Practice Address - Country:US
Practice Address - Phone:212-362-2260
Practice Address - Fax:212-362-2260
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1414092080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0672335Medicaid