Provider Demographics
NPI:1104821081
Name:LANDIS, MILES M (MD)
Entity type:Individual
Prefix:DR
First Name:MILES
Middle Name:M
Last Name:LANDIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 WAYMONT CT
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3485
Mailing Address - Country:US
Mailing Address - Phone:407-323-3550
Mailing Address - Fax:407-322-6127
Practice Address - Street 1:410 WAYMONT CT
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3485
Practice Address - Country:US
Practice Address - Phone:407-323-3550
Practice Address - Fax:407-322-6127
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51571174400000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD07050Medicare UPIN