=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366687360
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR MARK LANDAU
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2008
-----------------------------------------------------
Last Update Date | 12/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 VAN REED RD
-----------------------------------------------------
City | WYOMISSING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19610-1756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-378-5560
-----------------------------------------------------
Fax | 610-378-1400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 VAN REED RD
-----------------------------------------------------
City | WYOMISSING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19610-1756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-378-5560
-----------------------------------------------------
Fax | 610-378-1400
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARK F LANDAU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-378-5560
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OE005894T
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------