MEDICARE: LARRY JACKSON LANDRY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	ME95172	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00334279	OTHER	FL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	325257	OTHER	FL	WELLCARE
2	557262	OTHER	FL	AETNA
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	2836813001	OTHER	FL	CIGNA
6	37428	OTHER	FL	BLUE CROSS BLUE SHIELD
7	1226087	OTHER	FL	AETNA

General Provider Information

NPI Number	:	1134194608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY JACKSON LANDRY MD

Provider Business Mailing Address
First Line	:	240 N WICKHAM RD
Second Line	:	STE 104
City	:	MELBOURNE
State	:	FL
Zip	:	32935-8663
Country	:	US
Telephone Number	:	321-253-1992
Fax Number	:	321-253-1844

Provider Business Practice Location Address
First Line	:	2200 W EAU GALLIE BLVD
Second Line	:	SUITE 202A
City	:	MELBOURNE
State	:	FL
Zip	:	32935-3166
Country	:	US
Telephone Number	:	321-253-1992
Fax Number	:	321-253-1844

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2006
Last Update Date	:	04/08/2016

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Directions to “ LARRY JACKSON LANDRY MD” Practice Location

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