Provider Demographics
NPI:1770774713
Name:IDE, ERICA (MA)
Entity type:Individual
Prefix:MS
First Name:ERICA
Middle Name:
Last Name:IDE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 E 120TH ST
Mailing Address - Street 2:1079
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-3052
Mailing Address - Country:US
Mailing Address - Phone:310-668-4358
Mailing Address - Fax:
Practice Address - Street 1:1720 E 120TH ST
Practice Address - Street 2:1079
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3052
Practice Address - Country:US
Practice Address - Phone:310-668-4358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program