Healthcare Provider Details

I. General information

NPI: 1639142003
Provider Name (Legal Business Name): ALICIA M LANDRY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 01/07/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6875 DOUGLAS BLVD SUITE A
DOUGLASVILLE GA
30135-7133
US

IV. Provider business mailing address

3495 PIEDMONT RD NE NINE PIEDMONT CENTER
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 404-365-0966
  • Fax:
Mailing address:
  • Phone: 404-364-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number14917
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number58060
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: