Healthcare Provider Details

I. General information

NPI: 1710970876
Provider Name (Legal Business Name): CARL MICHAEL ERICKSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6542 SE LAKE RD STE 202
MILWAUKIE OR
97222-2245
US

IV. Provider business mailing address

6542 SE LAKE RD STE 202
MILWAUKIE OR
97222-2245
US

V. Phone/Fax

Practice location:
  • Phone: 503-233-5273
  • Fax: 855-492-8902
Mailing address:
  • Phone: 503-233-5273
  • Fax: 855-492-8902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberDO12690
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO12690
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: