Healthcare Provider Details

I. General information

NPI: 1639110331
Provider Name (Legal Business Name): KENNETH R. ERICKSON M.D., PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 04/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 NW SAMARITAN DR
CORVALLIS OR
97330-3766
US

IV. Provider business mailing address

3509 NW SAMARITAN DR
CORVALLIS OR
97330-3766
US

V. Phone/Fax

Practice location:
  • Phone: 541-768-5144
  • Fax: 541-768-5201
Mailing address:
  • Phone: 541-768-5144
  • Fax: 541-768-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD13119
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: