Healthcare Provider Details

I. General information

NPI: 1295476885
Provider Name (Legal Business Name): DANIEL MARK LANDIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WHETSTONE PL
ST AUGUSTINE FL
32086-5774
US

IV. Provider business mailing address

P O BOX 103204
GAINESVILLE FL
32610-0001
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-3777
  • Fax:
Mailing address:
  • Phone: 352-265-0651
  • Fax: 352-265-0153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME174686
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: