Healthcare Provider Details

I. General information

NPI: 1083689236
Provider Name (Legal Business Name): FRED S LANDES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 3RD AVE SE
ABERDEEN SD
57401-5418
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 605-725-1700
  • Fax: 605-725-1761
Mailing address:
  • Phone: 605-328-6585
  • Fax: 605-328-6512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4290
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number12144
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: