Provider Demographics
NPI:1194724740
Name:ERIKSSON, WAYNE RICHARD (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:RICHARD
Last Name:ERIKSSON
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 1:13880 BRADDOCK RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2459
Mailing Address - Country:US
Mailing Address - Phone:703-802-6304
Mailing Address - Fax:703-802-6307
Practice Address - Street 1:13880 BRADDOCK RD
Practice Address - Street 2:SUITE 201
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2459
Practice Address - Country:US
Practice Address - Phone:703-802-6304
Practice Address - Fax:703-802-6307
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048518208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics