Provider Demographics
NPI:1750508065
Name:ERICKSON, CHARLES G (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:G
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7208 SUGAR CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-5634
Mailing Address - Country:US
Mailing Address - Phone:402-420-3088
Mailing Address - Fax:
Practice Address - Street 1:1021 N 27TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68503-1803
Practice Address - Country:US
Practice Address - Phone:402-476-1455
Practice Address - Fax:402-476-1655
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11074208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE11074OtherSTATE LICENSE NUMBER