Healthcare Provider Details

I. General information

NPI: 1699394486
Provider Name (Legal Business Name): IAN LANDIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2020
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER ROAD
GAINESVILLE FL
32610-3001
US

IV. Provider business mailing address

PO BOX 100374
GAINESVILLE FL
32610-0374
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0291
  • Fax:
Mailing address:
  • Phone: 352-265-0291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME173925
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: