Provider Demographics
NPI:1952318016
Name:LAND, WILLIAM C JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:LAND
Suffix:JR
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:PO BOX 100041
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30156-9241
Mailing Address - Country:US
Mailing Address - Phone:770-779-2178
Mailing Address - Fax:
Practice Address - Street 1:11 UPPER RIVERDALE ROAD
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274
Practice Address - Country:US
Practice Address - Phone:770-991-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0154812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D45897Medicare UPIN