1275622466 NPI number — IAN LANDIS DO

Table of content: IAN LANDIS DO (NPI 1275622466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275622466 NPI number — IAN LANDIS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANDIS
Provider First Name:
IAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1275622466
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 RIVERWAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32963-2637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-231-6170
Provider Business Mailing Address Fax Number:
321-951-9253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5201 BABCOCK ST NE
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
PALM BAY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32905-4637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-676-5323
Provider Business Practice Location Address Fax Number:
321-951-9253
Provider Enumeration Date:
10/12/2006

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:  OS0004065 , 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: 102370 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 288660 . This is a "AMERIGROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: OS0004065 . This is a "WORKERS COMPENSATION" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1488395 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0782103 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 17030 . This is a "STAYWELL/HEALTHEASE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: V2489 . This is a "BCBS OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 16-00554 . This is a "UNITEDHEALTHCARE MEDIPASS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 820868 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: FDA 155978 . This is a "EMBRACED PROGRAM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1209448 . This is a "FIRST HEALTH/MAIL HANDLER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 40016 . This is a "FLORIDIANCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 042068900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com