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General NPI Number Information
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NPI Number | 1134194608
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Entity Type | Individual
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Provider Name | LARRY JACKSON LANDRY MD
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Gender | Male
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Dates
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Enumeration Date | 02/20/2006
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Last Update Date | 04/08/2016
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Provider Practice Location Address
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Address Line | 2200 W EAU GALLIE BLVD SUITE 202A
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City | MELBOURNE
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State | FL
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Zip | 32935-3166
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Country | US
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Telephone | 321-253-1992
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Fax | 321-253-1844
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Provider Business Mailing Address
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Address Line | 240 N WICKHAM RD STE 104
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City | MELBOURNE
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State | FL
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Zip | 32935-8663
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Country | US
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Telephone | 321-253-1992
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Fax | 321-253-1844
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | ME95172
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License Number State | FL
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