Provider Demographics
NPI:1477558856
Name:LANDT, MARK (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LANDT
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:PO BOX 722
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-0722
Mailing Address - Country:US
Mailing Address - Phone:970-926-5702
Mailing Address - Fax:970-926-5702
Practice Address - Street 1:37 ELK PLACE
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-0722
Practice Address - Country:US
Practice Address - Phone:970-926-5702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-3644207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000024299OtherANTHEM PIN#
OH0553995Medicaid
OH20-00775OtherUNHC PIN#
OH050045148OtherTRAVELERS PIN#
OH000000024299OtherANTHEM PIN#
OH0633641Medicare PIN