Provider Demographics
NPI:1225236771
Name:LANDIS, MARK ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
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:P.O. BOX 469
Mailing Address - Street 2:
Mailing Address - City:ERIN
Mailing Address - State:TN
Mailing Address - Zip Code:37061-0469
Mailing Address - Country:US
Mailing Address - Phone:931-289-4201
Mailing Address - Fax:931-289-4204
Practice Address - Street 1:4891 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ERIN
Practice Address - State:TN
Practice Address - Zip Code:37061-0469
Practice Address - Country:US
Practice Address - Phone:931-289-4201
Practice Address - Fax:931-289-4204
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000029891207Q00000X
TN29891207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5441903Medicaid
TNF51490Medicare UPIN
TN5441903Medicaid