Provider Demographics
NPI:1710928973
Name:LANDIS, ANDREW JAY (DPM)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JAY
Last Name:LANDIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 371
Mailing Address - Street 2:FOOT CENTER OF PERRY HALL
Mailing Address - City:PERRY HALL
Mailing Address - State:MD
Mailing Address - Zip Code:21128-0371
Mailing Address - Country:US
Mailing Address - Phone:410-256-1188
Mailing Address - Fax:410-256-1188
Practice Address - Street 1:4136 E JOPPA RD
Practice Address - Street 2:SUITE L
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-2286
Practice Address - Country:US
Practice Address - Phone:410-256-1188
Practice Address - Fax:410-256-1188
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00890213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD37024811 00Medicaid
MH39842201OtherBCBS NASCO
MDR5690001OtherFEDERAL BCBS
MDT217Medicare ID - Type Unspecified
MD37024811 00Medicaid
MDR5690001OtherFEDERAL BCBS