Individual
DR. TY BOLTON ERICKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
808 PANCHERI DRIVE, IDAHO FALLS, ID 83402-3344
(208) 552-6900
(208) 552-4973
Mailing address
2184 CHANNING WAY PMB #135, IDAHO FALLS, ID 83404-8034
(208) 552-6914
(208) 552-4973
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
6388670-1205
UT
207V00000X
Obstetrics & Gynecology Physician
Primary
M-6628
ID
207VF0040X
Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
6388670-1205
UT
207VF0040X
Urogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
M6628
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003678800
—
ID
Enumeration date
11/07/2006
Last updated
09/09/2014
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