Provider Demographics
NPI:1538203583
Name:LANDIS, BRADLEY (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:LANDIS
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 1:1300 N VERMONT AVE
Mailing Address - Street 2:#1003
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6005
Mailing Address - Country:US
Mailing Address - Phone:323-663-0077
Mailing Address - Fax:323-663-4501
Practice Address - Street 1:1300 N VERMONT AVE
Practice Address - Street 2:#1003
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6005
Practice Address - Country:US
Practice Address - Phone:323-663-0077
Practice Address - Fax:323-663-4501
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42058208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G420580Medicaid
CA00G420580Medicaid
A92304Medicare PIN