Provider Demographics
NPI:1609948827
Name:LANDRY, DANIEL P (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:P
Last Name:LANDRY
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 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:93 CAMPUS AVENUE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6030
Practice Address - Country:US
Practice Address - Phone:207-777-8442
Practice Address - Fax:207-777-8425
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD13374207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME3240685OtherAETNA
AX6934Medicare PIN
ME018118OtherANTHEM
MEF56343Medicare UPIN
ME050044663Medicare ID - Type UnspecifiedRAILROAD
MEMM5882Medicare ID - Type Unspecified
MEMM588201Medicare PIN
MEM92971OtherCIGNA
MEMN2064OtherHPHC
ME263220099Medicaid
NH30201140Medicaid