Provider Demographics
NPI:1518108588
Name:LANDRY, DALE THOMAS JR (MD)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:THOMAS
Last Name:LANDRY
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1034 MAR WALT DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6639
Mailing Address - Country:US
Mailing Address - Phone:850-863-2153
Mailing Address - Fax:850-315-9350
Practice Address - Street 1:1034 MAR WALT DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6639
Practice Address - Country:US
Practice Address - Phone:850-863-2153
Practice Address - Fax:850-315-9350
Is Sole Proprietor?:No
Enumeration Date:2009-03-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME 123092207XS0117X, 207XS0117X
FLME123092207X00000X
AZ48911207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL151CHOtherBCBS FL
FLAPPLYING ATN 598515OtherFL MEDICAID
Z170402OtherMEDICARE PTAN
FLME123092OtherMEDICAL LICENSE
FLME123092OtherMEDICAL LICENSE