Healthcare Provider Details

I. General information

NPI: 1275622466
Provider Name (Legal Business Name): IAN LANDIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 BABCOCK ST NE SUITE 5
PALM BAY FL
32905-4637
US

IV. Provider business mailing address

215 RIVERWAY DR
VERO BEACH FL
32963-2637
US

V. Phone/Fax

Practice location:
  • Phone: 321-676-5323
  • Fax: 321-951-9253
Mailing address:
  • Phone: 772-231-6170
  • Fax: 321-951-9253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS0004065
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: