Healthcare Provider Details

I. General information

NPI: 1790733269
Provider Name (Legal Business Name): SCOTT THOMAS LANDECK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2107 LIVINGSTON ST STE A
OAKLAND CA
94606-5218
US

IV. Provider business mailing address

30 BAYVIEW RD
KENTFIELD CA
94904-2617
US

V. Phone/Fax

Practice location:
  • Phone: 510-436-9013
  • Fax:
Mailing address:
  • Phone: 415-819-6129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG84442
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: