Provider Demographics
NPI:1316051154
Name:ERICKSON, GRAHAM BARCLAY (OD)
Entity type:Individual
Prefix:DR
First Name:GRAHAM
Middle Name:BARCLAY
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 1:2043 COLLEGE WAY
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-1756
Mailing Address - Country:US
Mailing Address - Phone:503-352-3197
Mailing Address - Fax:503-352-2929
Practice Address - Street 1:511 SW 10TH AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2732
Practice Address - Country:US
Practice Address - Phone:503-224-2323
Practice Address - Fax:503-352-2523
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2191T152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR208312Medicaid
ORU80127Medicare UPIN