Provider Demographics
NPI:1083709737
Name:LANDIS, MICHAEL EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:LANDIS
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 1:400 SENTARA CIR STE 350
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-5716
Mailing Address - Country:US
Mailing Address - Phone:757-736-7250
Mailing Address - Fax:757-510-9122
Practice Address - Street 1:400 SENTARA CIR STE 350
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5716
Practice Address - Country:US
Practice Address - Phone:757-736-7250
Practice Address - Fax:757-510-9122
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056946A2086S0129X
VA01012448512086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INF84530Medicare UPIN