Provider Demographics
NPI:1821079310
Name:ERICKSON, JOHN (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
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:PO BOX 28949
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-8949
Mailing Address - Country:US
Mailing Address - Phone:559-228-4200
Mailing Address - Fax:559-224-3920
Practice Address - Street 1:275 W HERNDON AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0204
Practice Address - Country:US
Practice Address - Phone:559-324-6200
Practice Address - Fax:559-324-6280
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55499207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G554990Medicaid
CA00G554990OtherBLUE CROSS/BLUE SHIELD
CA110125074OtherRAILROAD MEDICARE
CA77040368493612B011OtherCHAMPUS
CA00G554990OtherBLUE CROSS/BLUE SHIELD