1366499550 NPI number — A. DOUGLAS LANDERS MD

Table of content: A. DOUGLAS LANDERS MD (NPI 1366499550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366499550 NPI number — A. DOUGLAS LANDERS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANDERS
Provider First Name:
A. DOUGLAS
Provider Middle Name:
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:
LANDERS
Provider Other First Name:
ALLAN
Provider Other Middle Name:
DOUGLAS
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1366499550
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1027 WASHINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT LAKES
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56501-3409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-847-5611
Provider Business Mailing Address Fax Number:
218-847-0881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1027 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT LAKES
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56501-3409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-847-5611
Provider Business Practice Location Address Fax Number:
218-847-0881
Provider Enumeration Date:
05/31/2006

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: 2085R0202X , with the licence number:  0281722 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 14862 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP25796 . This is a "HEALTHPARTNERS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 14275 . This is a "SIOUX VALLEY #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 14566LA . This is a "MNBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 10028 . This is a "MNBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 283877000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 904873 . This is a "AMERICA'S PPO/ARAZ #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2012 . This is a "NDBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 28957LA . This is a "MNBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 92181LA . This is a "MNBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: ND200040 . This is a "LHS/BANNERHEALTH #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 142029 . This is a "UCARE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1602750 . This is a "MEDICA #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2608 . This is a "NDBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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