=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568548220
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN JOSEPH LAND IV DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 02/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1107 BROADRICK DR
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30720-2592
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-278-5558
-----------------------------------------------------
Fax | 706-278-6334
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1107 BROADRICK DR
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30720-2592
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-278-5558
-----------------------------------------------------
Fax | 706-278-6334
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | DPM0000000417
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | POD000679
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------