Provider Demographics
NPI:1790733269
Name:LANDECK, SCOTT THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:THOMAS
Last Name:LANDECK
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 1:30 BAYVIEW RD
Mailing Address - Street 2:
Mailing Address - City:KENTFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2617
Mailing Address - Country:US
Mailing Address - Phone:415-819-6129
Mailing Address - Fax:
Practice Address - Street 1:2107 LIVINGSTON ST STE A
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-5218
Practice Address - Country:US
Practice Address - Phone:510-436-9013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84442207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G844420Medicaid
CA00G844420Medicaid
CABI430ZMedicare PIN
CA00G844420Medicare PIN