1902096589 NPI number — MRS. KATHERINE ANN LANDIS O.D.

Table of content: MRS. KATHERINE ANN LANDIS O.D. (NPI 1902096589)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902096589 NPI number — MRS. KATHERINE ANN LANDIS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANDIS
Provider First Name:
KATHERINE
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COLLINS
Provider Other First Name:
KATHERINE
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902096589
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 W WALNUT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROGERS
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72756-3317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-636-2012
Provider Business Mailing Address Fax Number:
479-631-7416

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 W WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROGERS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72756-3317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-636-2012
Provider Business Practice Location Address Fax Number:
479-631-7416
Provider Enumeration Date:
07/30/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2594 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 185234722 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".