Provider Demographics
NPI:1649228131
Name:LAND, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:LAND
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:PO BOX 5579
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-5579
Mailing Address - Country:US
Mailing Address - Phone:541-548-7761
Mailing Address - Fax:541-526-6554
Practice Address - Street 1:1245 NW 4TH ST STE 101
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1680
Practice Address - Country:US
Practice Address - Phone:541-548-7761
Practice Address - Fax:541-526-6554
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23120174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH34444Medicare UPIN
OR115212Medicare ID - Type Unspecified