Provider Demographics
NPI:1407841216
Name:LANDICHO, GREGORIA B (MD)
Entity type:Individual
Prefix:
First Name:GREGORIA
Middle Name:B
Last Name:LANDICHO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1040 SIERRA DR
Mailing Address - Street 2:STE 400
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7240
Mailing Address - Country:US
Mailing Address - Phone:317-528-4248
Mailing Address - Fax:317-865-8314
Practice Address - Street 1:1501 WABASH
Practice Address - Street 2:SUITE #202
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360
Practice Address - Country:US
Practice Address - Phone:219-877-1965
Practice Address - Fax:219-877-1066
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01043004A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200046900Medicaid
G10266Medicare UPIN
IN170680BMedicare ID - Type Unspecified