Provider Demographics
NPI:1730182270
Name:LANDIS, GEORGE HAROLD (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:HAROLD
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 1:2805 CAMPUS DR STE 335
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2679
Mailing Address - Country:US
Mailing Address - Phone:952-562-5940
Mailing Address - Fax:952-562-5949
Practice Address - Street 1:2805 CAMPUS DR STE 335
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2679
Practice Address - Country:US
Practice Address - Phone:952-562-5940
Practice Address - Fax:952-562-5949
Is Sole Proprietor?:No
Enumeration Date:2005-05-29
Last Update Date:2024-03-11
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
MN346232086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN943224800Medicaid
MN943224800Medicaid
F81433Medicare UPIN