Provider Demographics
NPI:1629250436
Name:DEON RAE ERICKSON OD INC
Entity Type:Organization
Organization Name:DEON RAE ERICKSON OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:DEON
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:561-734-1887
Mailing Address - Street 1:3615 W WOOLBRIGHT RD
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-7244
Mailing Address - Country:US
Mailing Address - Phone:561-734-1887
Mailing Address - Fax:561-736-8991
Practice Address - Street 1:3615 W WOOLBRIGHT RD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-7244
Practice Address - Country:US
Practice Address - Phone:561-734-1887
Practice Address - Fax:561-736-8991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL2628152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084865400Medicaid
FL084865400Medicaid
FL3900630001Medicare NSC
FLK1979Medicare PIN