Provider Demographics
NPI:1871548438
Name:VANLANDINGHAM, SAMUEL B (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:B
Last Name:VANLANDINGHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6309
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46660-6309
Mailing Address - Country:US
Mailing Address - Phone:574-472-6700
Mailing Address - Fax:574-472-6746
Practice Address - Street 1:1919 LAKE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7830
Practice Address - Country:US
Practice Address - Phone:574-941-2967
Practice Address - Fax:574-941-2968
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036354208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000346996OtherBCBS
IN100251960Medicaid
INP00208549Medicare PIN
IN100251960Medicaid
IN000000346996OtherBCBS