Provider Demographics
NPI:1245262062
Name:LANDEFELD, RYAN (DO)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:LANDEFELD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2945
Mailing Address - Country:US
Mailing Address - Phone:814-373-4211
Mailing Address - Fax:814-373-4251
Practice Address - Street 1:765 LIBERTY ST
Practice Address - Street 2:SUITE # 307
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2566
Practice Address - Country:US
Practice Address - Phone:814-373-4211
Practice Address - Fax:814-373-4251
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012833207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014574970001Medicaid
PA092674ECCMedicare ID - Type Unspecified
PA1014574970001Medicaid