Provider Demographics
NPI:1174566046
Name:LANDER, JEFFREY KEITH (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:KEITH
Last Name:LANDER
Suffix:
Gender:M
Credentials:MD, PHD
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 3602
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92674-3602
Mailing Address - Country:US
Mailing Address - Phone:949-485-1812
Mailing Address - Fax:
Practice Address - Street 1:16300 SAND CANYON AVE
Practice Address - Street 2:SUITE 612
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3711
Practice Address - Country:US
Practice Address - Phone:949-753-1001
Practice Address - Fax:949-753-1115
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93332207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA93332BOtherMEDICARE PTAN
CA153701Medicare UPIN