Provider Demographics
NPI:1710430053
Name:GAGNON, ERICA (OD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:GAGNON
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 1:118 CASS AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2204
Mailing Address - Country:US
Mailing Address - Phone:586-468-7370
Mailing Address - Fax:
Practice Address - Street 1:3184 GRATIOT BLVD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-1488
Practice Address - Country:US
Practice Address - Phone:810-364-5520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005009152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist