Provider Demographics
NPI:1659341295
Name:LANDAN, IVAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:R
Last Name:LANDAN
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 1:557 SEMINOLE RD
Mailing Address - Street 2:
Mailing Address - City:NORTON SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:49444-3719
Mailing Address - Country:US
Mailing Address - Phone:231-722-7510
Mailing Address - Fax:231-722-7513
Practice Address - Street 1:557 SEMINOLE RD
Practice Address - Street 2:
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-3719
Practice Address - Country:US
Practice Address - Phone:231-722-7510
Practice Address - Fax:231-722-7513
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0489732084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2776688Medicaid
MI2776688Medicaid
MI0610099Medicare ID - Type Unspecified