Basic Information
| Provider Information | |||||||||
| NPI: | 1477940674 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DR. MARC LANDES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DR. LANDES AND ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2234 CROSS CREEK TRL | ||||||||
| Address2: | |||||||||
| City: | CUYAHOGA FALLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442231273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306062880 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 905 SINGLETARY DR | ||||||||
| Address2: | |||||||||
| City: | STREETSBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442413975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304222168 | ||||||||
| FaxNumber: | 3304222170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2015 | ||||||||
| LastUpdateDate: | 01/27/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LANDES | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | TODD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3306062880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DR. MARC LANDES | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 6212 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0085936 | 05 | OH | MEDICAID |