Provider Demographics
NPI:1497770994
Name:LANDER, ELLIOT BARTON (MD)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:BARTON
Last Name:LANDER
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 1:72780 COUNTRY CLUB DR STE C-301
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-4126
Mailing Address - Country:US
Mailing Address - Phone:760-776-0040
Mailing Address - Fax:760-776-0041
Practice Address - Street 1:72780 COUNTRY CLUB DR STE C-301
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4126
Practice Address - Country:US
Practice Address - Phone:760-776-0040
Practice Address - Fax:760-776-0041
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG624900208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G624900Medicaid
CA00G624900Medicare ID - Type Unspecified
CA00G624900Medicaid