Provider Demographics
NPI:1053361162
Name:LANDE, IAN (MD)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:LANDE
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 1:3015 WILLIAMS DR
Mailing Address - Street 2:STE 200
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4623
Mailing Address - Country:US
Mailing Address - Phone:703-641-9133
Mailing Address - Fax:703-280-5098
Practice Address - Street 1:4445 WILLARD AVE
Practice Address - Street 2:STE 200
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-3690
Practice Address - Country:US
Practice Address - Phone:301-654-4242
Practice Address - Fax:703-280-5098
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0033140174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
E53242Medicare UPIN
129361W85Medicare ID - Type UnspecifiedMC INDIVIDUAL PROVIDER #
VA019479W24Medicare PIN