Provider Demographics
NPI:1780681775
Name:ERICKSON, SCOTT
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SCOTT ERICKSON
Mailing Address - Street 2:440 MEDICAL DR
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4950
Mailing Address - Country:US
Mailing Address - Phone:807-294-8288
Mailing Address - Fax:801-294-8488
Practice Address - Street 1:440 MEDICAL DR
Practice Address - Street 2:SUITE 4
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4950
Practice Address - Country:US
Practice Address - Phone:807-294-8288
Practice Address - Fax:801-294-8488
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5836179-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD6126Medicaid
UTP00363584Medicare PIN
I03311Medicare UPIN
UT005805101Medicare PIN