Provider Demographics
NPI:1518128719
Name:ERICKSON, MALRY FOSTER (MD)
Entity type:Individual
Prefix:DR
First Name:MALRY
Middle Name:FOSTER
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:FOSTER
Other - Last Name:LUMPKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:21001 N TATUM BLVD
Mailing Address - Street 2:STE 1630-431
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4206
Mailing Address - Country:US
Mailing Address - Phone:480-375-3451
Mailing Address - Fax:
Practice Address - Street 1:1452 N HIGLEY RD
Practice Address - Street 2:STE 101
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-1610
Practice Address - Country:US
Practice Address - Phone:480-374-3451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37280208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ454486Medicaid
AZZ132536Medicare PIN