Provider Demographics
NPI:1225272073
Name:MEDVEC, LANDRU DEREK (IDMT)
Entity Type:Individual
Prefix:
First Name:LANDRU
Middle Name:DEREK
Last Name:MEDVEC
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 CENTRAL AVE
Mailing Address - Street 2:SUITE 1M07
Mailing Address - City:EIELSON AFB
Mailing Address - State:AK
Mailing Address - Zip Code:99702-2301
Mailing Address - Country:US
Mailing Address - Phone:907-377-6526
Mailing Address - Fax:907-377-2763
Practice Address - Street 1:2422 ARCTIC AVE
Practice Address - Street 2:APT D
Practice Address - City:EIELSON AFB
Practice Address - State:AK
Practice Address - Zip Code:99702
Practice Address - Country:US
Practice Address - Phone:907-372-4458
Practice Address - Fax:907-372-4458
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians