Provider Demographics
NPI:1891898821
Name:ERIKSEN, LANCE R (MD)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:R
Last Name:ERIKSEN
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 1:171 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2517
Mailing Address - Country:US
Mailing Address - Phone:203-757-8919
Mailing Address - Fax:203-756-4697
Practice Address - Street 1:171 GRANDVIEW AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2517
Practice Address - Country:US
Practice Address - Phone:203-757-8919
Practice Address - Fax:203-756-4697
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT017909207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT070000092OtherMEDICARE PROVIDER #
CT001179092Medicaid
13935OtherSTATE CONTROLED SUB
13935OtherSTATE CONTROLED SUB
B39644Medicare UPIN
CT017909Medicare ID - Type UnspecifiedLICENSE