MEDICARE: IAN LANDIS DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	OS0004065	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	120001775	OTHER	FL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	102370	OTHER	FL	AVMED
2	288660	OTHER	FL	AMERIGROUP
3	OS0004065	OTHER	FL	WORKERS COMPENSATION
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	1488395	OTHER	FL	UNITED HEALTHCARE
7	0782103	OTHER	FL	CIGNA
8	17030	OTHER	FL	STAYWELL/HEALTHEASE
9	V2489	OTHER	FL	BCBS OF FLORIDA
10	16-00554	OTHER	FL	UNITEDHEALTHCARE MEDIPASS
11	820868	OTHER	FL	AETNA
12	FDA 155978	OTHER	FL	EMBRACED PROGRAM
13	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
14	1209448	OTHER	FL	FIRST HEALTH/MAIL HANDLER
15	40016	OTHER	FL	FLORIDIANCARE
16	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275622466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IAN LANDIS DO

Provider Business Mailing Address
First Line	:	215 RIVERWAY DR
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32963-2637
Country	:	US
Telephone Number	:	772-231-6170
Fax Number	:	321-951-9253

Provider Business Practice Location Address
First Line	:	5201 BABCOCK ST NE
Second Line	:	SUITE 5
City	:	PALM BAY
State	:	FL
Zip	:	32905-4637
Country	:	US
Telephone Number	:	321-676-5323
Fax Number	:	321-951-9253

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	11/28/2007

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Directions to “ IAN LANDIS DO” Practice Location

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