Basic Information
Provider Information | |||||||||
NPI: | 1831538552 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LANDES | ||||||||
FirstName: | MARC | ||||||||
MiddleName: | TODD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 06/15/2013 | ||||||||
LastUpdateDate: | 01/19/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 6212 | OH | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 0085936 | 05 | OH |   | MEDICAID | 0129078 | 05 | OH |   | MEDICAID |