Provider Demographics
NPI:1508967910
Name:NICHOLAS LANDRY D.O. INC.
Entity Type:Organization
Organization Name:NICHOLAS LANDRY D.O. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:V
Authorized Official - Last Name:LANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:740-441-9800
Mailing Address - Street 1:1325 NORTHUP RD
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-8830
Mailing Address - Country:US
Mailing Address - Phone:740-441-9800
Mailing Address - Fax:740-441-9400
Practice Address - Street 1:1354 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-2601
Practice Address - Country:US
Practice Address - Phone:740-441-9800
Practice Address - Fax:740-441-9400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5630097000Medicaid
WV$$$$$$$$$OtherSOCIAL SECURITY NUMBER
OH2144067Medicaid
OH000000303053OtherANTHEM
OH9333152Medicare PIN
OH2144067Medicaid