Provider Demographics
NPI:1790799716
Name:ERICKSON, MARK THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
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 1:3700 PIPER ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4665
Mailing Address - Country:US
Mailing Address - Phone:907-269-7152
Mailing Address - Fax:907-269-7246
Practice Address - Street 1:3700 PIPER ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4665
Practice Address - Country:US
Practice Address - Phone:907-269-7152
Practice Address - Fax:907-269-7246
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3995207Q00000X, 103T00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD96081Medicaid
AK8EK884Medicare PIN
AK8EL676Medicare PIN
AK8EC257Medicare ID - Type Unspecified
AK8EL673Medicare PIN
AK8EJ968Medicare PIN
AK8EL675Medicare PIN
AK8EE737Medicare PIN
AK8EL674Medicare PIN
AKF68664Medicare UPIN
AKMD96081Medicaid