Provider Demographics
NPI:1700050960
Name:LANDER, GISELLE A (OD)
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:A
Last Name:LANDER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5035 MAYFIELD RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2688
Mailing Address - Country:US
Mailing Address - Phone:216-291-2020
Mailing Address - Fax:216-291-2057
Practice Address - Street 1:5035 MAYFIELD RD
Practice Address - Street 2:SUITE 110
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-2688
Practice Address - Country:US
Practice Address - Phone:216-291-2020
Practice Address - Fax:216-291-2057
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3717152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0697287Medicaid
OHT48775Medicare UPIN
OH0697287Medicaid