Basic Information
| Provider Information | |||||||||
| NPI: | 1821187436 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANDIS | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 631 PROFESSIONAL DRIVE | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300467651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709638030 | ||||||||
| FaxNumber: | 7703399577 | ||||||||
| Practice Location | |||||||||
| Address1: | 631 PROFESSIONAL DRIVE | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300467651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709638030 | ||||||||
| FaxNumber: | 7703399577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 01/29/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 021733 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1821187436 | 01 | GA | PROVIDER NPI NUMBER | OTHER | 00245506J | 05 | GA | MEDICAID | 1508926759 | 01 | GA | GROUP NPI NUMBER | OTHER |