Provider Demographics
NPI:1457374431
Name:LANDIS, ANJA OCTAVIA (MD)
Entity Type:Individual
Prefix:
First Name:ANJA
Middle Name:OCTAVIA
Last Name:LANDIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:50 ROOSEVELT TER
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-3517
Practice Address - Country:US
Practice Address - Phone:570-808-8780
Practice Address - Fax:570-808-8785
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233487207Q00000X
PAMD445002207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027272920001Medicaid