Provider Demographics
NPI:1932156916
Name:LANDIS, GREGG S (MD)
Entity type:Individual
Prefix:
First Name:GREGG
Middle Name:S
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 1:1999 MARCUS AVE
Mailing Address - Street 2:SUITE 106B
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1033
Mailing Address - Country:US
Mailing Address - Phone:516-233-3607
Mailing Address - Fax:718-962-2239
Practice Address - Street 1:1999 MARCUS AVE
Practice Address - Street 2:SUITE 106B
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1033
Practice Address - Country:US
Practice Address - Phone:516-233-3607
Practice Address - Fax:718-962-2239
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221796208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00770KOtherMEDICARE PTAN - NYHMCQ-AMBSURG
NY02270024Medicaid
NYP00262367OtherRAILROAD MEDICARE - CRT
NYP00262367OtherRAILROAD MEDICARE - CRT
NY00770KOtherMEDICARE PTAN - NYHMCQ-AMBSURG
NY02017QMedicare ID - Type Unspecified