Provider Demographics
NPI:1659338929
Name:ERICKSON, DEON RAE (OD INC)
Entity Type:Individual
Prefix:
First Name:DEON
Middle Name:RAE
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:OD INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2628152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084865400Medicaid
FL084865400Medicaid
FL20420ZMedicare PIN
FL3900630001Medicare NSC