Healthcare Provider Details

I. General information

NPI: 1366480998
Provider Name (Legal Business Name): JOE TRE LANDRUM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 09/21/2025
Certification Date: 09/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 FINLEY DR
ADA OK
74820-5392
US

IV. Provider business mailing address

730 FINLEY DR
ADA OK
74820-5392
US

V. Phone/Fax

Practice location:
  • Phone: 580-421-6470
  • Fax:
Mailing address:
  • Phone: 580-421-6470
  • Fax: 580-421-6472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number4310
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: