Provider Demographics
NPI:1063407583
Name:VERKLEEREN, ERICA WOLFF (MD)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:WOLFF
Last Name:VERKLEEREN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-873-1244
Practice Address - Street 1:15 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:NY
Practice Address - Zip Code:14801-1140
Practice Address - Country:US
Practice Address - Phone:607-359-2291
Practice Address - Fax:607-359-2294
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241430207Q00000X
MA213846207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02825212Medicaid
NY02825212Medicaid
MAA34328Medicare ID - Type Unspecified
NYJ400067045Medicare PIN