Provider Demographics
NPI:1689987695
Name:ZEIDERS, ERICA M (OD)
Entity Type:Individual
Prefix:DR
First Name:ERICA
Middle Name:M
Last Name:ZEIDERS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5241 S STATE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4841
Mailing Address - Country:US
Mailing Address - Phone:801-281-3937
Mailing Address - Fax:801-281-1430
Practice Address - Street 1:5241 S STATE ST STE 1
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4841
Practice Address - Country:US
Practice Address - Phone:801-281-3937
Practice Address - Fax:801-281-1430
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10202277-9934152W00000X
MI4901004631152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI502720028Medicare PIN