Healthcare Provider Details

I. General information

NPI: 1144584160
Provider Name (Legal Business Name): JOHN ERICKSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 08/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 CHILDRENS WAY
JACKSONVILLE FL
32207-8426
US

IV. Provider business mailing address

PO BOX 191
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 904-697-3600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2012020517
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOPC4789
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: