Provider Demographics
NPI:1932259587
Name:ERICKSON, STEPHEN T (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:T
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 SHERIDAN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-2901
Mailing Address - Country:US
Mailing Address - Phone:360-385-5388
Mailing Address - Fax:360-385-0433
Practice Address - Street 1:1010 SHERIDAN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-2901
Practice Address - Country:US
Practice Address - Phone:360-385-5388
Practice Address - Fax:360-385-0433
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI39311207Q00000X
CO48329207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32423500Medicaid
CO25939742Medicaid
WI32423500Medicaid
COCO306423Medicare PIN