Provider Demographics
NPI:1013071455
Name:ERICKSON, TODD (OD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 W CENTER ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-4032
Mailing Address - Country:US
Mailing Address - Phone:406-755-5171
Mailing Address - Fax:406-755-5182
Practice Address - Street 1:340 W CENTER ST
Practice Address - Street 2:SUITE B
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4032
Practice Address - Country:US
Practice Address - Phone:406-755-5171
Practice Address - Fax:406-755-5182
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT593152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT048-3769Medicaid
MT048-3769Medicaid