Provider Demographics
NPI:1285683987
Name:LANDRUM, MARILYN M (MD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:M
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 S US HIGHWAY 75 STE 300
Mailing Address - Street 2:ATTN BILLING
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-4589
Mailing Address - Country:US
Mailing Address - Phone:903-416-6025
Mailing Address - Fax:
Practice Address - Street 1:5012 S US HIGHWAY 75
Practice Address - Street 2:SUITE 300
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-4587
Practice Address - Country:US
Practice Address - Phone:930-416-6025
Practice Address - Fax:903-416-6138
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0363208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100229300AMedicaid
TX042108301Medicaid
OK100229300AMedicaid
TX83517KMedicare PIN