Provider Demographics
NPI:1558704171
Name:LANDGRAF D O, ROBERT L
Entity Type:Organization
Organization Name:LANDGRAF D O, ROBERT L
Other - Org Name:FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:LANDGRAF
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:707-423-4355
Mailing Address - Street 1:2560 N TEXAS ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-1649
Mailing Address - Country:US
Mailing Address - Phone:707-423-4355
Mailing Address - Fax:707-423-4353
Practice Address - Street 1:2560 N TEXAS ST
Practice Address - Street 2:SUITE C
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-1649
Practice Address - Country:US
Practice Address - Phone:707-423-4355
Practice Address - Fax:707-423-4353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7022261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOAX70220Medicaid
CAOOAX70220Medicaid