Provider Demographics
NPI:1366499550
Name:LANDERS, A. DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:A. DOUGLAS
Middle Name:
Last Name:LANDERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ALLAN
Other - Middle Name:DOUGLAS
Other - Last Name:LANDERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1027 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3409
Mailing Address - Country:US
Mailing Address - Phone:218-847-5611
Mailing Address - Fax:218-847-0881
Practice Address - Street 1:1027 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3409
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:218-847-0881
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN02817222085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN14862Medicaid
MNHP25796OtherHEALTHPARTNERS #
MN14275OtherSIOUX VALLEY #
MN14566LAOtherMNBS #
MN10028OtherMNBS #
MN283877000Medicaid
MN904873OtherAMERICA'S PPO/ARAZ #
ND2012OtherNDBS #
MN28957LAOtherMNBS #
ND92181LAOtherMNBS #
NDND200040OtherLHS/BANNERHEALTH #
MN142029OtherUCARE #
MN1602750OtherMEDICA #
MN2608OtherNDBS #
NDND200040OtherLHS/BANNERHEALTH #
MN2608OtherNDBS #
MN309000835Medicare ID - Type UnspecifiedMN MEDICARE #
MN28957LAOtherMNBS #
MN14862Medicaid