Provider Demographics
NPI:1710970876
Name:ERICKSON, CARL MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:MICHAEL
Last Name:ERICKSON
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 1:6542 SE LAKE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2245
Mailing Address - Country:US
Mailing Address - Phone:503-233-5273
Mailing Address - Fax:855-492-8902
Practice Address - Street 1:6542 SE LAKE RD STE 202
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2245
Practice Address - Country:US
Practice Address - Phone:503-233-5273
Practice Address - Fax:855-492-8902
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO12690204C00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR120000019OtherMEDICARE RAILROAD
OR226639Medicaid
OR120000019OtherMEDICARE RAILROAD
ORD38480Medicare UPIN
OR0000BHPDXRMedicare PIN