Basic Information
| Provider Information | |||||||||
| NPI: | 1366499550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDERS | ||||||||
| FirstName: | A. DOUGLAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LANDERS | ||||||||
| OtherFirstName: | ALLAN | ||||||||
| OtherMiddleName: | DOUGLAS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 05/07/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0281722 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 14862 | 05 | MN | MEDICAID | HP25796 | 01 | MN | HEALTHPARTNERS # | OTHER | 14275 | 01 | MN | SIOUX VALLEY # | OTHER | 14566LA | 01 | MN | MNBS # | OTHER | 10028 | 01 | MN | MNBS # | OTHER | 283877000 | 05 | MN | MEDICAID | 904873 | 01 | MN | AMERICA'S PPO/ARAZ # | OTHER | 2012 | 01 | ND | NDBS # | OTHER | 28957LA | 01 | MN | MNBS # | OTHER | 92181LA | 01 | ND | MNBS # | OTHER | ND200040 | 01 | ND | LHS/BANNERHEALTH # | OTHER | 142029 | 01 | MN | UCARE # | OTHER | 1602750 | 01 | MN | MEDICA # | OTHER | 2608 | 01 | MN | NDBS # | OTHER |