Healthcare Provider Details

I. General information

NPI: 1821132754
Provider Name (Legal Business Name): DEVAUGHN ERICKSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 MAIN AVE N
ROSEAU MN
56751-1820
US

IV. Provider business mailing address

306 MAIN AVE N
ROSEAU MN
56751-1820
US

V. Phone/Fax

Practice location:
  • Phone: 218-463-2020
  • Fax: 218-463-2055
Mailing address:
  • Phone: 218-463-2020
  • Fax: 218-463-2055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1618
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: