MEDICARE: COREY L ERICKSEN DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	171802-1204	UT

General Provider Information

NPI Number	:	1912003922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COREY L ERICKSEN DO

Provider Business Mailing Address
First Line	:	1762 VIEW CT
Second Line	:
City	:	FRUIT HEIGHTS
State	:	UT
Zip	:	84037-6704
Country	:	US
Telephone Number	:	801-628-8877
Fax Number	:

Provider Business Practice Location Address
First Line	:	1762 VIEWCOURT
Second Line	:
City	:	FRUIT HEIGHTS
State	:	UT
Zip	:	84037
Country	:	US
Telephone Number	:	801-628-8877
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	10/21/2019

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