Provider Demographics
NPI:1285718387
Name:LANDRUM, HARRY J JR (OD)
Entity type:Individual
Prefix:DR
First Name:HARRY
Middle Name:J
Last Name:LANDRUM
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:MULLICA HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08062-1504
Mailing Address - Country:US
Mailing Address - Phone:856-223-9100
Mailing Address - Fax:856-223-1626
Practice Address - Street 1:10 BAKER BLVD
Practice Address - Street 2:
Practice Address - City:MULLICA HILL
Practice Address - State:NJ
Practice Address - Zip Code:08062-1504
Practice Address - Country:US
Practice Address - Phone:856-223-9100
Practice Address - Fax:856-223-1626
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27TO00052500152W00000X
NJ27OA00448000152W00000X
PAOEG0011641152W00000X
PAOA4480152W00000X
PATO00525152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2014109OtherAETNA
NJ802547OtherAMERIHEALTH
NJ232334180OtherUNITED HEALTHCARE
NJAMERHEALTH PPOOther232334180
NJ6091601Medicaid
PA401703OtherKEYSTONE HEALTH PLAN EAST
NJ2014109OtherAETNA
NJAMERHEALTH PPOOther232334180
NJLA802547Medicare ID - Type Unspecified