Provider Demographics
NPI:1942390232
Name:ERICKSON, DAVID ALAN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALAN
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 1:1005 MAR WALT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6707
Mailing Address - Country:US
Mailing Address - Phone:850-863-8150
Mailing Address - Fax:850-863-4152
Practice Address - Street 1:1005 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6707
Practice Address - Country:US
Practice Address - Phone:850-863-8203
Practice Address - Fax:850-863-8113
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME152070208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111509700Medicaid
IL036099760Medicaid
ILL72371Medicare ID - Type UnspecifiedINDIVIDUAL #
H01538Medicare UPIN