Provider Demographics
NPI:1194718106
Name:ERICKSON, THOMAS L (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:L
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1780 E FLORENCE BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85222-4782
Mailing Address - Country:US
Mailing Address - Phone:520-836-8988
Mailing Address - Fax:520-836-7930
Practice Address - Street 1:1780 E FLORENCE BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-4782
Practice Address - Country:US
Practice Address - Phone:520-836-8988
Practice Address - Fax:520-836-7930
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2010-07-09
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
AZ14731207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ242008Medicaid
AZC99434Medicare UPIN
AZ242008Medicaid