Provider Demographics
NPI:1417189416
Name:JOSEPH W LANDAU M D A MEDICAL CORP
Entity type:Organization
Organization Name:JOSEPH W LANDAU M D A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:W
Authorized Official - Last Name:LANDAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-828-4494
Mailing Address - Street 1:2428 SANTA MONICA BLVD
Mailing Address - Street 2:STE 401
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2047
Mailing Address - Country:US
Mailing Address - Phone:310-828-4494
Mailing Address - Fax:310-828-3254
Practice Address - Street 1:2428 SANTA MONICA BLVD
Practice Address - Street 2:STE 401
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2047
Practice Address - Country:US
Practice Address - Phone:310-828-4494
Practice Address - Fax:310-828-3254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-10
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG4281207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000G42810Medicaid
CA05D0549998OtherCLIA
CA1609801760OtherVARIOUS INSURANCE COMPANIES
CAG4281OtherVARIOUS INSURANCE COMPANIES
CAA56440Medicare UPIN
CA1609801760OtherVARIOUS INSURANCE COMPANIES