Healthcare Provider Details

I. General information

NPI: 1528061371
Provider Name (Legal Business Name): GUNNAR JON ERICKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 FAIRVIEW BLVD
WYOMING MN
55092-8013
US

IV. Provider business mailing address

5200 FAIRVIEW BLVD
WYOMING MN
55092-8013
US

V. Phone/Fax

Practice location:
  • Phone: 651-257-8421
  • Fax: 651-257-8464
Mailing address:
  • Phone: 651-257-8421
  • Fax: 651-257-8464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number24279
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: