Provider Demographics
NPI:1952338808
Name:ERICKSEN, M (MD)
Entity Type:Individual
Prefix:
First Name:M
Middle Name:
Last Name:ERICKSEN
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 1:100 N. MARIO CAPECCHI DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1103
Mailing Address - Country:US
Mailing Address - Phone:801-662-3578
Mailing Address - Fax:
Practice Address - Street 1:100 N. MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-3578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT363155-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT77988OtherHEALTHY U
ID806196700Medicaid
WY120083600Medicaid
UT36315512000001OtherBCBS
UT693497OtherDESERET MUTUAL
AZ878407Medicaid
UT100504905OtherFIRST HEALTH
UT219176OtherALTIUS
UT78899OtherPEHP
MT0153221Medicaid
UT870280408MTYOtherEDUCATORS MUTUAL
UTPRA06245OtherMOLINA