Provider Demographics
NPI:1972601425
Name:LANDIS, TIMOTHY DONALD (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DONALD
Last Name:LANDIS
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 1:5 PINE WEST PLZ
Mailing Address - Street 2:SUITE 510
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-5587
Mailing Address - Country:US
Mailing Address - Phone:518-690-0203
Mailing Address - Fax:
Practice Address - Street 1:1A PINE WEST PLZ
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-5557
Practice Address - Country:US
Practice Address - Phone:518-862-1665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210815-1174400000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY210815-1OtherNEW YORK STATE EDUCATION LICENSE