Provider Demographics
NPI:1861414849
Name:LANDIS, ERIC TYLER (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:TYLER
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 1:5960 FAIRVIEW RD STE 500
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3113
Mailing Address - Country:US
Mailing Address - Phone:704-495-6334
Mailing Address - Fax:704-817-7219
Practice Address - Street 1:10635 PARK RD STE I
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8408
Practice Address - Country:US
Practice Address - Phone:704-495-6025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC92947207R00000X
NC200000867207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN00868Medicaid
NC127G7OtherBCBS
NC89127G7Medicaid
NC1861414849Medicaid
NC2281111KMedicare PIN
2281111GMedicare PIN
110229716Medicare PIN
NC127G7OtherBCBS
NC2281111JMedicare PIN