Provider Demographics
NPI:1174516967
Name:LANDES, MICHAEL D (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:LANDES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:580-548-1112
Mailing Address - Fax:580-548-1538
Practice Address - Street 1:401 S 3RD ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5737
Practice Address - Country:US
Practice Address - Phone:580-548-1112
Practice Address - Fax:580-548-1538
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK31092207Q00000X
OH35057984L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9327331Medicare ID - Type Unspecified
OH0774461Medicaid