Provider Demographics
NPI:1649209065
Name:INGRAM, ERIC (RPT)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:
Last Name:INGRAM
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3751
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95063-3751
Mailing Address - Country:US
Mailing Address - Phone:831-457-1800
Mailing Address - Fax:831-457-1802
Practice Address - Street 1:1003 RIVER ST
Practice Address - Street 2:C
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1754
Practice Address - Country:US
Practice Address - Phone:831-457-1800
Practice Address - Fax:831-457-1802
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008448225100000X
CA257272251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAP477ZOtherPTAN