Provider Demographics
NPI:1902886914
Name:LANDRUM, SAMUEL EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:EDWARD
Last Name:LANDRUM
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:PO BOX 1824
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72902-1824
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:479-709-7053
Practice Address - Street 1:1001 TOWSON AVE.
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901
Practice Address - Country:US
Practice Address - Phone:479-441-5361
Practice Address - Fax:479-441-5078
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR1721208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105606001Medicaid
OK100251020AMedicaid
AR53028Medicare ID - Type Unspecified
AR105606001Medicaid