Provider Demographics
NPI:1760451165
Name:LANDDECK, DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:LANDDECK
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 1:1900 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5467
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:315 W OAK ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-2150
Practice Address - Country:US
Practice Address - Phone:920-887-9272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI34940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIG04943Medicare UPIN