Provider Demographics
NPI:1992781538
Name:LANDRY, NICHOLAS VITO (DO)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:VITO
Last Name:LANDRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 NORTHUP RD
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-8830
Mailing Address - Country:US
Mailing Address - Phone:740-441-9800
Mailing Address - Fax:740-441-9400
Practice Address - Street 1:1354 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-2601
Practice Address - Country:US
Practice Address - Phone:740-441-9800
Practice Address - Fax:740-441-9400
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006760207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000303053OtherANTHEM
OH300147896027OtherCORESOURCE
OH2144067Medicaid
WV5630097000Medicaid
OH7108004OtherAETNA
OH340066272001OtherMEDICAL MUTUAL OF OHIO
OH340066272007OtherMEDICAL MUTUAL OF OMAHA
OH340066272007OtherMEDICAL MUTUAL OF OMAHA
OH000000303053OtherANTHEM
OH340066272001OtherMEDICAL MUTUAL OF OHIO
OH300147896OtherTAX ID NUMBER
OH0892026Medicare PIN