Provider Demographics
NPI:1134194608
Name:LANDRY, LARRY JACKSON (MD)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:JACKSON
Last Name:LANDRY
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 1:240 N WICKHAM RD
Mailing Address - Street 2:STE 104
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8663
Mailing Address - Country:US
Mailing Address - Phone:321-253-1992
Mailing Address - Fax:321-253-1844
Practice Address - Street 1:2200 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE 202A
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3166
Practice Address - Country:US
Practice Address - Phone:321-253-1992
Practice Address - Fax:321-253-1844
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95172208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL325257OtherWELLCARE
FL557262OtherAETNA
FLP00334279OtherRAILROAD MEDICARE
FL274787100Medicaid
FL2836813001OtherCIGNA
FL37428OtherBLUE CROSS BLUE SHIELD
FL1226087OtherAETNA
C46085Medicare UPIN
FL274787100Medicaid