Healthcare Provider Details

I. General information

NPI: 1144212317
Provider Name (Legal Business Name): RONALD J LANDIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11108 PARKVIEW CIRCLE DR
FORT WAYNE IN
46845-1730
US

IV. Provider business mailing address

1234 E DUPONT RD SUITE 3
FORT WAYNE IN
46825-1545
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-5700
  • Fax: 260-266-5920
Mailing address:
  • Phone: 260-373-7875
  • Fax: 260-373-9705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01027533A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number01027533A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: