1134194608 NPI number — LARRY JACKSON LANDRY MD

Table of content: MADILYN E TOMASO MD (NPI 1780264002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134194608 NPI number — LARRY JACKSON LANDRY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANDRY
Provider First Name:
LARRY
Provider Middle Name:
JACKSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134194608
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 N WICKHAM RD
Provider Second Line Business Mailing Address:
STE 104
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32935-8663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-253-1992
Provider Business Mailing Address Fax Number:
321-253-1844

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 W EAU GALLIE BLVD
Provider Second Line Business Practice Location Address:
SUITE 202A
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32935-3166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-253-1992
Provider Business Practice Location Address Fax Number:
321-253-1844
Provider Enumeration Date:
02/20/2006

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: 208800000X , with the licence number:  ME95172 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 325257 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 557262 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P00334279 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 274787100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2836813001 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 37428 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1226087 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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