Provider Demographics
NPI:1336209873
Name:ERICKSON, KENT (MD)
Entity type:Individual
Prefix:DR
First Name:KENT
Middle Name:
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 1:17183 I 45 S STE 550
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77385-3314
Mailing Address - Country:US
Mailing Address - Phone:936-270-3800
Mailing Address - Fax:
Practice Address - Street 1:17183 I 45 S STE 550
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385-3314
Practice Address - Country:US
Practice Address - Phone:936-270-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00J21AOtherGROUP MEDICARE NUMBER
TX094010801OtherGROUP MEDICAID NUMBER
TX153879513Medicaid
TX153879511Medicaid
TX153879512Medicaid
TX153879506Medicaid
TX349867YKTXMedicare PIN
TX349867YKTUMedicare PIN