Provider Demographics
NPI:1184799520
Name:KENNETH LANDIS M D A MEDICAL CORPORATION
Entity type:Organization
Organization Name:KENNETH LANDIS M D A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:LANDIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-822-2255
Mailing Address - Street 1:4644 LINCOLN BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6313
Mailing Address - Country:US
Mailing Address - Phone:310-822-2255
Mailing Address - Fax:310-822-0044
Practice Address - Street 1:4644 LINCOLN BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6313
Practice Address - Country:US
Practice Address - Phone:310-822-2255
Practice Address - Fax:310-822-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29787207RC0200X, 207RP1001X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G297871Medicaid
CA290003222OtherRAILROAD MEDICARE
CP9010OtherMEDICARE RRR
CA00G297870Medicaid