Healthcare Provider Details

I. General information

NPI: 1407841216
Provider Name (Legal Business Name): GREGORIA B LANDICHO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 WABASH SUITE #202
MICHIGAN CITY IN
46360
US

IV. Provider business mailing address

1040 SIERRA DR STE 400
GREENWOOD IN
46143-7240
US

V. Phone/Fax

Practice location:
  • Phone: 219-877-1965
  • Fax: 219-877-1066
Mailing address:
  • Phone: 317-528-4248
  • Fax: 317-865-8314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01043004A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: