Provider Demographics
NPI:1982753133
Name:ERICKSON COSTELLO BUTLER ERICKSON OPTOMETRIST PA
Entity type:Organization
Organization Name:ERICKSON COSTELLO BUTLER ERICKSON OPTOMETRIST PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-582-3383
Mailing Address - Street 1:1280 W LANTANA RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LANTANA
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1543
Mailing Address - Country:US
Mailing Address - Phone:561-582-3383
Mailing Address - Fax:561-582-8821
Practice Address - Street 1:1280 W LANTANA RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-1543
Practice Address - Country:US
Practice Address - Phone:561-582-3383
Practice Address - Fax:561-582-8821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP000675152W00000X
FLOP0001024152W00000X
FLOP0002227152W00000X
FLOP0002687152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1639129869OtherNPI NUMBER DR. SANDY COST
FL620476700Medicaid
FL1508817099OtherNPI NUMBER DR. DAVID BUTL
FL1528019080OtherNPI NUMBER DR. NEIL ERICK
FL1497705917OtherNPI NUMBER DR. TODD ERICK
FL1639129869OtherNPI NUMBER DR. SANDY COST
FL1508817099OtherNPI NUMBER DR. DAVID BUTL
FL1528019080OtherNPI NUMBER DR. NEIL ERICK