Provider Demographics
NPI:1710950928
Name:LAND, ROGER LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:LYNN
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 1:5022 OLD GODSEY LANE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4085
Mailing Address - Country:US
Mailing Address - Phone:423-870-4435
Mailing Address - Fax:423-870-4685
Practice Address - Street 1:5022 OLD GODSEY LANE
Practice Address - Street 2:SUITE 10
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4085
Practice Address - Country:US
Practice Address - Phone:423-870-4435
Practice Address - Fax:423-870-4685
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD21156174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3058053Medicare PIN