Provider Demographics
NPI:1427148485
Name:ERICKSON, LEIF E (OD)
Entity type:Individual
Prefix:DR
First Name:LEIF
Middle Name:E
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15601 RAILROAD ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-6527
Mailing Address - Country:US
Mailing Address - Phone:715-634-8616
Mailing Address - Fax:
Practice Address - Street 1:15601 RAILROAD ST
Practice Address - Street 2:SUITE 301
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-6527
Practice Address - Country:US
Practice Address - Phone:715-634-8616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1306-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI22704OtherSECURITY HEALTH
WI38568600Medicaid
WI4U216EROtherATRIUM
WI11727OtherNVA & PROVANTAGE
WI22-00507OtherMEDICA
WI38568600OtherGROUP HEALTH
WI26011RMedicaid
WI87217Medicaid
WI1001441OtherPREFERRED ONE
WI38568600OtherHEALTH RISK
WI39-1131290OtherSELECT CARE & CBSA
WI46988OtherHEALTH PARTNERS
WI87213OtherTRI CARE
WI1001441OtherPREFERRED ONE
WI87217Medicaid