Provider Demographics
NPI:1902020332
Name:ERICKSON, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
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 700
Mailing Address - Street 2:
Mailing Address - City:BOLING
Mailing Address - State:TX
Mailing Address - Zip Code:77420-0700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 RAILROAD ST.
Practice Address - Street 2:
Practice Address - City:BOLING
Practice Address - State:TX
Practice Address - Zip Code:77420
Practice Address - Country:US
Practice Address - Phone:979-657-4000
Practice Address - Fax:979-657-3800
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE57462083T0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083T0002XAllopathic & Osteopathic PhysiciansPreventive MedicineMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB22558Medicare UPIN