Provider Demographics
NPI:1568548220
Name:LAND, JOHN JOSEPH IV (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:LAND
Suffix:IV
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1107 BROADRICK DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2592
Mailing Address - Country:US
Mailing Address - Phone:706-278-5558
Mailing Address - Fax:706-278-6334
Practice Address - Street 1:1107 BROADRICK DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2592
Practice Address - Country:US
Practice Address - Phone:706-278-5558
Practice Address - Fax:706-278-6334
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM0000000417213E00000X
GAPOD000679213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1440694OtherUMWA
GA52432145OtherBC BS
GA000828385AMedicaid
TN3124909OtherBCBS
TN3351905Medicare ID - Type Unspecified
U33730Medicare UPIN
GA000828385AMedicaid
480027427Medicare ID - Type UnspecifiedRAIL ROAD