Healthcare Provider Details

I. General information

NPI: 1376685370
Provider Name (Legal Business Name): JOHN C LAND MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 NW 4TH ST STE 101
REDMOND OR
97756-1363
US

IV. Provider business mailing address

1245 NW 4TH ST STE 101
REDMOND OR
97756-1363
US

V. Phone/Fax

Practice location:
  • Phone: 541-548-7761
  • Fax: 541-526-6554
Mailing address:
  • Phone: 541-548-7761
  • Fax: 541-526-6554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD23120
License Number StateOR

VIII. Authorized Official

Name: JOHN C LAND
Title or Position: PRESIDENT
Credential: MD PC
Phone: 541-548-7761