Provider Demographics
NPI:1831306968
Name:PRYOR, LANDON S (MD)
Entity type:Individual
Prefix:DR
First Name:LANDON
Middle Name:S
Last Name:PRYOR
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 1:5995 SPRING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-6481
Mailing Address - Country:US
Mailing Address - Phone:815-977-4403
Mailing Address - Fax:815-977-5796
Practice Address - Street 1:5995 SPRING CREEK RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-6481
Practice Address - Country:US
Practice Address - Phone:815-977-4403
Practice Address - Fax:815-977-5796
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99159208200000X
IL036124349208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036124349Medicaid
IL10132215OtherBCBS