Provider Demographics
NPI:1821187436
Name:LANDIS, ANTHONY M (DO)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:M
Last Name:LANDIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:631 PROFESSIONAL DRIVE
Mailing Address - Street 2:SUITE 450
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-7651
Mailing Address - Country:US
Mailing Address - Phone:770-963-8030
Mailing Address - Fax:770-339-9577
Practice Address - Street 1:631 PROFESSIONAL DRIVE
Practice Address - Street 2:SUITE 450
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7651
Practice Address - Country:US
Practice Address - Phone:770-963-8030
Practice Address - Fax:770-339-9577
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA021733207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1821187436OtherPROVIDER NPI NUMBER
GA00245506JMedicaid
GA1508926759OtherGROUP NPI NUMBER
GA00245506JMedicaid
GA4188940002Medicare NSC
GA1821187436OtherPROVIDER NPI NUMBER
900003457Medicare PIN