Provider Demographics
NPI:1164510319
Name:LANDRUM, GEORGE W (MD)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:W
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 1:4729 E UNION HILLS DR
Mailing Address - Street 2:# 111
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-3390
Mailing Address - Country:US
Mailing Address - Phone:602-482-5444
Mailing Address - Fax:602-482-5666
Practice Address - Street 1:4729 E UNION HILLS DR
Practice Address - Street 2:# 111
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-3390
Practice Address - Country:US
Practice Address - Phone:602-482-5444
Practice Address - Fax:602-482-5666
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20340207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ054479Medicaid
AZD54090Medicare UPIN
AZ054479Medicaid