Healthcare Provider Details

I. General information

NPI: 1790799716
Provider Name (Legal Business Name): MARK THOMAS ERICKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 PIPER ST
ANCHORAGE AK
99508-4665
US

IV. Provider business mailing address

3700 PIPER ST
ANCHORAGE AK
99508-4665
US

V. Phone/Fax

Practice location:
  • Phone: 907-269-7152
  • Fax: 907-269-7246
Mailing address:
  • Phone: 907-269-7152
  • Fax: 907-269-7246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3995
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3995
License Number StateAK
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number3995
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: