Provider Demographics
NPI:1639110331
Name:ERICKSON, KENNETH R (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3509 NW SAMARITAN DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3766
Mailing Address - Country:US
Mailing Address - Phone:541-768-5144
Mailing Address - Fax:541-768-5201
Practice Address - Street 1:3509 NW SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3766
Practice Address - Country:US
Practice Address - Phone:541-768-5144
Practice Address - Fax:541-768-5201
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD131192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORC92591Medicare UPIN