Provider Demographics
NPI:1275622466
Name:LANDIS, IAN (DO)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:LANDIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 RIVERWAY DR
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-2637
Mailing Address - Country:US
Mailing Address - Phone:772-231-6170
Mailing Address - Fax:321-951-9253
Practice Address - Street 1:5201 BABCOCK ST NE
Practice Address - Street 2:SUITE 5
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4637
Practice Address - Country:US
Practice Address - Phone:321-676-5323
Practice Address - Fax:321-951-9253
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS00040652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102370OtherAVMED
FL288660OtherAMERIGROUP
FLOS0004065OtherWORKERS COMPENSATION
FL1488395OtherUNITED HEALTHCARE
FL0782103OtherCIGNA
FL17030OtherSTAYWELL/HEALTHEASE
FLV2489OtherBCBS OF FLORIDA
FL16-00554OtherUNITEDHEALTHCARE MEDIPASS
FL820868OtherAETNA
FLFDA 155978OtherEMBRACED PROGRAM
FL1209448OtherFIRST HEALTH/MAIL HANDLER
FL40016OtherFLORIDIANCARE
FL1209448OtherFIRST HEALTH/MAIL HANDLER
FL16-00554OtherUNITEDHEALTHCARE MEDIPASS