Healthcare Provider Details

I. General information

NPI: 1043135841
Provider Name (Legal Business Name): MATT JOSEPH LANDOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18765 GAUCHE RD
FAYETTEVILLE OH
45118-9647
US

IV. Provider business mailing address

18765 GAUCHE RD
FAYETTEVILLE OH
45118-9647
US

V. Phone/Fax

Practice location:
  • Phone: 513-888-5538
  • Fax:
Mailing address:
  • Phone: 513-888-5538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: