Provider Demographics
NPI:1073502670
Name:LANDRY, KEITH PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:PETER
Last Name:LANDRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 508
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:IN
Mailing Address - Zip Code:46120-0508
Mailing Address - Country:US
Mailing Address - Phone:765-795-4242
Mailing Address - Fax:765-795-4456
Practice Address - Street 1:51 EAST MARKET STREET
Practice Address - Street 2:
Practice Address - City:CLOVERDALE
Practice Address - State:IN
Practice Address - Zip Code:46120
Practice Address - Country:US
Practice Address - Phone:765-795-4242
Practice Address - Fax:765-795-4456
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057298A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200818260FMedicaid
IN7289687OtherAETNA
IN000000361385OtherANTHEM BLUE CROSS & BLUE
IN9339207OtherCIGNA
IN200818260FMedicaid
INI17269Medicare UPIN