Provider Demographics
NPI:1912003922
Name:ERICKSEN, COREY L (DO)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:L
Last Name:ERICKSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1762 VIEW CT
Mailing Address - Street 2:
Mailing Address - City:FRUIT HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84037-6704
Mailing Address - Country:US
Mailing Address - Phone:801-628-8877
Mailing Address - Fax:
Practice Address - Street 1:1762 VIEWCOURT
Practice Address - Street 2:
Practice Address - City:FRUIT HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84037
Practice Address - Country:US
Practice Address - Phone:801-628-8877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT171802-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E35353Medicare UPIN
UT000000268Medicare ID - Type Unspecified