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General NPI Number Information
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NPI Number | 1285956797
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Entity Type | Individual
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Provider Name | MATTHEW CAMPBELL ERICKSEN D.O.
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Gender | Male
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Dates
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Enumeration Date | 02/25/2010
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Last Update Date | 12/05/2024
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Provider Practice Location Address
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Address Line | 1155 W PARKVIEW ST SUITE 2J
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City | BOLIVAR
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State | MO
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Zip | 65613-8279
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Country | US
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Telephone | 417-328-7000
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Fax |
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Provider Business Mailing Address
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Address Line | 1801 SE HILLMOOR DR STE B-105
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City | PORT ST LUCIE
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State | FL
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Zip | 34952-7545
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Country | US
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Telephone | 772-398-9911
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YX0905X
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Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
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License Number | 2012015105
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License Number State | MO
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