Healthcare Provider Details

I. General information

NPI: 1154060762
Provider Name (Legal Business Name): SAMUEL GLEN ERICKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 STANTON L YOUNG BLVD AAT 1464
OKLAHOMA CITY OK
73104-5018
US

IV. Provider business mailing address

800 STANTON L YOUNG BLVD AAT 1464
OKLAHOMA CITY OK
73104-5018
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-5504
  • Fax:
Mailing address:
  • Phone: 405-271-5504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number39489
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number39489
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: