Provider Demographics
NPI:1154318772
Name:LANDIS, BRUCE RICHARD (OD)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:RICHARD
Last Name:LANDIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 S MAIN ST
Mailing Address - Street 2:PO BOX 100
Mailing Address - City:ELKADER
Mailing Address - State:IA
Mailing Address - Zip Code:52043-0100
Mailing Address - Country:US
Mailing Address - Phone:563-245-2304
Mailing Address - Fax:563-245-2392
Practice Address - Street 1:202 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ELKADER
Practice Address - State:IA
Practice Address - Zip Code:52043-9078
Practice Address - Country:US
Practice Address - Phone:563-245-2304
Practice Address - Fax:563-245-2392
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1715152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0069633Medicaid
T82774Medicare UPIN
27863Medicare ID - Type Unspecified