Provider Demographics
NPI:1447253885
Name:LANDIS, GREGORY C (OD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:C
Last Name:LANDIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4305
Mailing Address - Country:US
Mailing Address - Phone:208-743-2020
Mailing Address - Fax:208-743-3583
Practice Address - Street 1:3201 5TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-743-2020
Practice Address - Fax:087-433-5832
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3948/T1027152W00000X
IDODP-100426152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000117385OtherANTHEM BC/BS
OH2201051OtherUHC
OH5886015OtherAETNA
OH0729082Medicaid
OHT81981Medicare UPIN
OH2201051OtherUHC