1194758136 NPI number — DENNIS M LANDIS MD

Table of content: DENNIS M LANDIS MD (NPI 1194758136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194758136 NPI number — DENNIS M LANDIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANDIS
Provider First Name:
DENNIS
Provider Middle Name:
M
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:
1194758136
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 418283
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-8283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-558-1544
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3800 RESERVOIR RD NW
Provider Second Line Business Practice Location Address:
GEORGETOWN UNIVERSITY HOSP; DEPT. NEUROLOGY
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20007-2113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-444-8525
Provider Business Practice Location Address Fax Number:
877-245-1499
Provider Enumeration Date:
07/09/2006

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: 2084P0800X , with the licence number:  35-052989 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: MD037989 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0613401 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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