MEDICARE: DR. DALE THOMAS LANDRY JR. M.D.

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	207XS0117X	Orthopaedic Surgery of the Spine Physician	ME 123092	FL
2	207X00000X	Orthopaedic Surgery Physician	ME123092	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	Z170402	OTHER		MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	151CH	OTHER	FL	BCBS FL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	ME123092	OTHER	FL	MEDICAL LICENSE

General Provider Information

NPI Number	:	1518108588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DALE THOMAS LANDRY JR. M.D.

Provider Business Mailing Address
First Line	:	1034 MAR WALT DR
Second Line	:	SUITE 100
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-6639
Country	:	US
Telephone Number	:	850-863-2153
Fax Number	:	850-315-9350

Provider Business Practice Location Address
First Line	:	1034 MAR WALT DR
Second Line	:	SUITE 100
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-6639
Country	:	US
Telephone Number	:	850-863-2153
Fax Number	:	850-315-9350

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

Provider Enumeration Date	:	03/20/2009
Last Update Date	:	03/07/2023

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Directions to “ DR. DALE THOMAS LANDRY JR. M.D.” Practice Location

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