Basic Information
| Provider Information | |||||||||
| NPI: | 1790118115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDERO | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | EDNA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 FALL CREEK HWY | ||||||||
| Address2: | |||||||||
| City: | GRANBURY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104619820 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 601 FALL CREEK HWY | ||||||||
| Address2: | |||||||||
| City: | GRANBURY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760497960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173263900 | ||||||||
| FaxNumber: | 8175788903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2013 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 29399 | PR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | Q9181 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 362366201 | 05 | TX | MEDICAID |