Healthcare Provider Details

I. General information

NPI: 1306988977
Provider Name (Legal Business Name): ROBERT MARTIN LANDAW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11633 SAN VICENTE BLVD #206
LA CA
90049-6513
US

IV. Provider business mailing address

11633 SAN VICENTE BLVD #206
LA CA
90049-6513
US

V. Phone/Fax

Practice location:
  • Phone: 310-826-5513
  • Fax: 310-820-1606
Mailing address:
  • Phone: 310-826-5513
  • Fax: 310-820-1606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG9814
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: