Provider Demographics
NPI:1528169620
Name:ERICKSON, DOUGLAS J (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
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 1:5301 VIRGINIA WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7542
Mailing Address - Country:US
Mailing Address - Phone:615-221-4474
Mailing Address - Fax:615-234-3774
Practice Address - Street 1:5301 VIRGINIA WAY STE 300
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7542
Practice Address - Country:US
Practice Address - Phone:615-221-4474
Practice Address - Fax:615-234-3774
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11969207ZP0102X
GA23950207ZP0102X
KY39356207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN000000026731OtherTLC TENNCARE
TN3881727Medicaid
TN146106OtherUNISON TENNCARE
GA52025911003OtherBLUE CROSS
TN4060457OtherBLUE CROSS
GA319846OtherWELLCARE CMO
KY64070576Medicaid
TN4060457OtherBLUE CROSS
TN3881727Medicare ID - Type Unspecified
GA319846OtherWELLCARE CMO
F26124Medicare UPIN
GA22BDDPTMedicare ID - Type Unspecified