Provider Demographics
NPI:1932280104
Name:LANDRUM, MICHAEL LEROY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEROY
Last Name:LANDRUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-3456
Practice Address - Fax:920-433-3469
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01054143A207RI0200X
WI56939207RI0200X
MI4301503113207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ABIM-MOCOtherAMERICAN BOARD OF INTERNAL MEDICINE/INFECTIOUS DISEASE