1417189416 NPI number — JOSEPH W LANDAU M D A MEDICAL CORP

Table of content: (NPI 1417189416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417189416 NPI number — JOSEPH W LANDAU M D A MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOSEPH W LANDAU M D A MEDICAL CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1417189416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2428 SANTA MONICA BLVD
Provider Second Line Business Mailing Address:
STE 401
Provider Business Mailing Address City Name:
SANTA MONICA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90404-2047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-828-4494
Provider Business Mailing Address Fax Number:
310-828-3254

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2428 SANTA MONICA BLVD
Provider Second Line Business Practice Location Address:
STE 401
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90404-2047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-828-4494
Provider Business Practice Location Address Fax Number:
310-828-3254
Provider Enumeration Date:
08/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LANDAU
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT/SECRETARY
Authorized Official Telephone Number:
310-828-4494

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  G4281 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000G42810 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05D0549998 . This is a "CLIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1609801760 . This is a "VARIOUS INSURANCE COMPANIES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G4281 . This is a "VARIOUS INSURANCE COMPANIES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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