Provider Demographics
NPI:1679001945
Name:PEDERSON, ERIC (DO)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 E MONROE ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-1400
Mailing Address - Country:US
Mailing Address - Phone:605-755-4060
Mailing Address - Fax:605-755-4012
Practice Address - Street 1:502 E MONROE ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-1400
Practice Address - Country:US
Practice Address - Phone:605-755-4060
Practice Address - Fax:605-755-4012
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD12132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAOT017562OtherPA MEDICAL LICENSE